Healthcare Provider Details

I. General information

NPI: 1437781366
Provider Name (Legal Business Name): EAGLE CLASSIC WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2020
Last Update Date: 02/08/2020
Certification Date: 02/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 S WESTERN AVE
LOS ANGELES CA
90018-1537
US

IV. Provider business mailing address

1914 S WESTERN AVE
LOS ANGELES CA
90018-1537
US

V. Phone/Fax

Practice location:
  • Phone: 909-229-2721
  • Fax:
Mailing address:
  • Phone: 909-229-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name: DOCK JU CHEONG
Title or Position: PRESIDENT
Credential:
Phone: 909-229-2721