Healthcare Provider Details

I. General information

NPI: 1053964015
Provider Name (Legal Business Name): STEPHEN HYUNJIN CHANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PEARTREE LN
ROLLING HILLS ESTATES CA
90274-4824
US

IV. Provider business mailing address

19 PEARTREE LN
ROLLING HILLS ESTATES CA
90274-4824
US

V. Phone/Fax

Practice location:
  • Phone: 213-820-7492
  • Fax:
Mailing address:
  • Phone: 213-820-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC17413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: