Basic Information
| Provider Information | |||||||||
| NPI: | 1790265577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | XU | ||||||||
| FirstName: | KE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSC. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | XU | ||||||||
| OtherFirstName: | KEREN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSC. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6268 N SAN GABRIEL BLVD. | ||||||||
| Address2: | APT 17 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262107496 | ||||||||
| FaxNumber: | 6265772305 | ||||||||
| Practice Location | |||||||||
| Address1: | 9353 VALLEY BLVD C ROSEMEND,ASIAN PACIFIC FAMILY CENTER | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262872988 | ||||||||
| FaxNumber: | 6265772305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225C00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
ID Information
| ID | Type | State | Issuer | Description | XEK906417606 | 01 | CA | BLUE SHIELD | OTHER |