Healthcare Provider Details

I. General information

NPI: 1417882028
Provider Name (Legal Business Name): CHULGI YEOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHARLIE YEOM

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9580 GARDEN GROVE BLVD STE 105
GARDEN GROVE CA
92844-1589
US

IV. Provider business mailing address

2237 STRICKLER DR
FULLERTON CA
92833-5623
US

V. Phone/Fax

Practice location:
  • Phone: 714-590-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number253764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: