MEDICARE: JULIE EUNJEONG MIN N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	RN 517212 NP 12611	CA

General Provider Information

NPI Number	:	1154399566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE EUNJEONG MIN N.P.

Provider Business Mailing Address
First Line	:	2846 S CAROLINA ST
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-6618
Country	:	US
Telephone Number	:	310-833-1257
Fax Number	:

Provider Business Practice Location Address
First Line	:	1251 W REDONDO BEACH BLVD
Second Line	:	3RD FLOOR
City	:	GARDENA
State	:	CA
Zip	:	90247-3456
Country	:	US
Telephone Number	:	310-851-4705
Fax Number	:	310-851-4719

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	07/08/2007

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