Healthcare Provider Details

I. General information

NPI: 1093244006
Provider Name (Legal Business Name): BONGSILL CHUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 EAST 120TH ST
LOS ANGELES CA
90059
US

IV. Provider business mailing address

21209 BLOOMFIELD AVE
LAKEWOOD CA
90715
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-2366
  • Fax: 310-223-0361
Mailing address:
  • Phone: 562-405-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number357813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: