Healthcare Provider Details

I. General information

NPI: 1225432164
Provider Name (Legal Business Name): THERESA JUNG-SUN MIN MSOM, R.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42350 GRAND RIVER AVE
NOVI MI
48375-1838
US

IV. Provider business mailing address

42350 GRAND RIVER AVE
NOVI MI
48375-1838
US

V. Phone/Fax

Practice location:
  • Phone: 248-697-2942
  • Fax: 248-436-6628
Mailing address:
  • Phone: 248-697-2942
  • Fax: 248-436-6628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5401000143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: