Provider Demographics
NPI:1891235578
Name:SOUTH COUNTY KIDNEY AND ENDOCRINE CENTER
Entity type:Organization
Organization Name:SOUTH COUNTY KIDNEY AND ENDOCRINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:KU JAY
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-916-9100
Mailing Address - Street 1:23141 MOULTON PKWY #102
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-916-9100
Mailing Address - Fax:949-916-0091
Practice Address - Street 1:23141 MOULTON PKWY STE 102
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1241
Practice Address - Country:US
Practice Address - Phone:949-916-9100
Practice Address - Fax:949-916-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202278889251K00000X
251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare