Healthcare Provider Details

I. General information

NPI: 1154399566
Provider Name (Legal Business Name): JULIE EUNJEONG MIN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: EUNJEONG MIN N.P.

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 W REDONDO BEACH BLVD 3RD FLOOR
GARDENA CA
90247-3456
US

IV. Provider business mailing address

2846 S CAROLINA ST
SAN PEDRO CA
90731-6618
US

V. Phone/Fax

Practice location:
  • Phone: 310-851-4705
  • Fax: 310-851-4719
Mailing address:
  • Phone: 310-833-1257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN 517212 NP 12611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: