=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669581393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YONG AT HEART TOTAL WELLNESS MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 03/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16838 CLARK ST STE C
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-789-0203
-----------------------------------------------------
Fax | 818-789-0208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16628 OAK VIEW CT
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-989-1892
-----------------------------------------------------
Fax | 818-789-0208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARJORIE MEIJI YONG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-989-1892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | A61406
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------