=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033457171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. CHUNG ACUPUNCTURE CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2013
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 S CHEVY CHASE DR #104
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91205-4431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-517-6940
-----------------------------------------------------
Fax | 818-937-9335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4711 LOWELL AVE
-----------------------------------------------------
City | LA CRESCENTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91214-1636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-517-6940
-----------------------------------------------------
Fax | 818-937-9335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HYUN SOO CHUNG
-----------------------------------------------------
Credential | D.A.O.M.,L.AC.
-----------------------------------------------------
Telephone | 818-517-6940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC12319
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------