=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942211347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EUGENE MING SU DC, MAOM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 SW 74TH ST #220
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33143-5165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-692-9362
-----------------------------------------------------
Fax | 703-723-6647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44330 PREMIER PLZ #110
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-5070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-723-9355
-----------------------------------------------------
Fax | 703-723-6647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 004126442205
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10465
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------