Healthcare Provider Details

I. General information

NPI: 1295272193
Provider Name (Legal Business Name): KOYAMA CHIROPRACTIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12629 W WASHINGTON BLVD
LOS ANGELES CA
90066-2303
US

IV. Provider business mailing address

12629 W WASHINGTON BLVD
LOS ANGELES CA
90066-2303
US

V. Phone/Fax

Practice location:
  • Phone: 310-391-6125
  • Fax:
Mailing address:
  • Phone: 310-391-6125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC31898
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC14432
License Number StateCA

VIII. Authorized Official

Name: TAESUNG BYUN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 310-391-6125