Healthcare Provider Details

I. General information

NPI: 1114171626
Provider Name (Legal Business Name): SANGSOON CHANG D.O.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 JUAN TABO BLVD NE
ALBUQUERQUE NM
87112-2966
US

IV. Provider business mailing address

12406 NEW DAWN RD NE # RDNE
ALBUQUERQUE NM
87122-4304
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-7504
  • Fax:
Mailing address:
  • Phone: 505-710-7504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number960
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: