=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255580213
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMI KYUNGRI CHUNG MS, CCC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2008
-----------------------------------------------------
Last Update Date | 02/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E VALENCIA MESA DR STE 111
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-441-0133
-----------------------------------------------------
Fax | 714-441-1082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E VALENCIA MESA DR STE 111
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-441-0133
-----------------------------------------------------
Fax | 714-441-1082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | HTL8467
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | AU2628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------