Basic Information
| Provider Information | |||||||||
| NPI: | 1356754659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAK | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 877 OAK PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PISMO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934493292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054748450 | ||||||||
| FaxNumber: | 8054748454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 20A14324 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 20A14324 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.