=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740806538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SO CAL INTEGRATED MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2020
-----------------------------------------------------
Last Update Date | 06/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 N PRAIRIE AVE
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-4878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-245-8480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 S FLOWER ST UNIT 613
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-245-8480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SEUNG WAN HONG
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 213-245-8480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------