MEDICARE: MIRAE CLINIC

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	261Q00000X	Clinic/Center	8306	TX

General Provider Information

NPI Number	:	1164668588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRAE CLINIC

Provider Business Mailing Address
First Line	:	2035 ROYAL LN STE 280
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75229-3268
Country	:	US
Telephone Number	:	214-352-6677
Fax Number	:	877-643-4072

Provider Business Practice Location Address
First Line	:	2035 ROYAL LN STE 280
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75229-3268
Country	:	US
Telephone Number	:	214-352-6677
Fax Number	:	877-643-4072

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID KOH
Credential	:	D.C.
Telephone Number	:	214-352-6677

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	01/07/2009

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Directions to “MIRAE CLINIC ” Practice Location

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