=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396005476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MK HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2012
-----------------------------------------------------
Last Update Date | 06/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14104 BROOKHURST ST
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92843-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-636-3886
-----------------------------------------------------
Fax | 714-636-3459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14104 BROOKHURST ST
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92843-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-636-3886
-----------------------------------------------------
Fax | 714-636-3459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JUNGHEE JASON KIM
-----------------------------------------------------
Credential | L.AC
-----------------------------------------------------
Telephone | 714-636-3886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | AC12178
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------