=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659865392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YM LIFE TREE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2018
-----------------------------------------------------
Last Update Date | 06/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13901 AMAR RD # AB7-8
-----------------------------------------------------
City | LA PUENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91746-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-392-8962
-----------------------------------------------------
Fax | 626-364-3083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13901 AMAR RD # AB7-8
-----------------------------------------------------
City | LA PUENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91746-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-392-8962
-----------------------------------------------------
Fax | 626-364-3083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | HYEONGJIN YOUN
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 714-392-8962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC16993
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------