Healthcare Provider Details

I. General information

NPI: 1336705680
Provider Name (Legal Business Name): TONY CHUNG DACM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20272 CARREY RD
WALNUT CA
91789-2302
US

IV. Provider business mailing address

16226 POCONO ST
LA PUENTE CA
91744-3245
US

V. Phone/Fax

Practice location:
  • Phone: 626-474-3864
  • Fax:
Mailing address:
  • Phone: 626-330-6826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC18523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: