=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902450364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JISUN RYU ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2019
-----------------------------------------------------
Last Update Date | 04/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 E WEST HWY # 404
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-423-6393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 EAST WEST HWY SUITE 404
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED ACUPUNCTURIST
-----------------------------------------------------
Name | JISUN RYU
-----------------------------------------------------
Credential | L.AC
-----------------------------------------------------
Telephone | 607-423-6393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------