=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194734418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANGWOO MAH, D.C., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 11/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15001 NORTHERN BLVD 1ST FLOOR
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-746-4919
-----------------------------------------------------
Fax | 718-746-4920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15001 NORTHERN BLVD 1ST FLOOR
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-746-4919
-----------------------------------------------------
Fax | 718-746-4920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SANGWOO MAH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 718-746-4919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X009835
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------