Healthcare Provider Details

I. General information

NPI: 1770966475
Provider Name (Legal Business Name): KOYAMA CHIROPRACTIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
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: 310-391-7117
Mailing address:
  • Phone: 310-391-6125
  • Fax: 310-391-7117

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: OWNER/ PRESIDENT
Credential:
Phone: 310-391-6125