Healthcare Provider Details

I. General information

NPI: 1114477387
Provider Name (Legal Business Name): JISUN RYU L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 E WEST HWY STE 404
BETHESDA MD
20814-4523
US

IV. Provider business mailing address

4401 E WEST HWY STE 404
BETHESDA MD
20814-4523
US

V. Phone/Fax

Practice location:
  • Phone: 607-423-6393
  • Fax:
Mailing address:
  • Phone: 607-423-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: