=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013897990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOREAN TRADITIONAL ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2025
-----------------------------------------------------
Last Update Date | 09/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4056 WETHERBURN WAY STE 203
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-4613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-523-4057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4056 WETHERBURN WAY STE 203
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-4613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYONGHWAN YANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-524-5251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------