=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144950148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LLIAS W CHUNG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2022
-----------------------------------------------------
Last Update Date | 06/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8282 WILLETT PKWY
-----------------------------------------------------
City | BALDWINSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13027-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-857-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5563 PERTH CRSE
-----------------------------------------------------
City | CLAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13041-6850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-317-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------