=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124456975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEYSTONE MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 10/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1014 S 320TH ST STE C
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-5344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-689-6268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16243 SE 326TH ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98092-5907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-689-6268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAI JUN BYEON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 360-689-6268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | MD44106
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------