=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912410879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAESEONG INTEGRATIVE MEDICINE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2017
-----------------------------------------------------
Last Update Date | 11/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 S VIRGIL AVE STE 306
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-944-0214
-----------------------------------------------------
Fax | 213-603-8000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 S VIRGIL AVE STE 306
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-944-0214
-----------------------------------------------------
Fax | 213-603-8000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST/ CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. ON JUNG PARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-944-0214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC14308
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------