=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295272193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOYAMA CHIROPRACTIC CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2017
-----------------------------------------------------
Last Update Date | 01/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12629 W WASHINGTON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-391-6125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12629 W WASHINGTON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-391-6125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TAESUNG BYUN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 310-391-6125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC14432
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC31898
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------