=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700166535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONG SHIN D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2011
-----------------------------------------------------
Last Update Date | 08/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13226 AVERY AVE STE 1A
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-4954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-888-7972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13226 AVERY AVE STE 1A
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-4954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-888-7972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 007348
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------