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General NPI Number Information
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NPI Number | 1952667065
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Entity Type | Organization
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Legal Business Name | MOON CHIROPRACTIC GROUP, INC
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 04/03/2012
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Provider Practice Location Address
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Address Line | 2560 W OLYMPIC BLVD STE 304
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City | LOS ANGELES
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State | CA
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Zip | 90006-2972
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Country | US
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Telephone | 213-388-9994
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Fax |
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Provider Business Mailing Address
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Address Line | 2560 W OLYMPIC BLVD STE 304
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City | LOS ANGELES
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State | CA
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Zip | 90006-2972
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | DR. JIMMY J BAE
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Credential | D.C.
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Telephone | 213-388-9994
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 29321
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License Number State | CA
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