Provider Demographics
NPI:1083144695
Name:NANUM ACUPUNCTURE PC
Entity Type:Organization
Organization Name:NANUM ACUPUNCTURE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:JANG HEON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:347-237-7564
Mailing Address - Street 1:6325 MARATHON PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2338
Mailing Address - Country:US
Mailing Address - Phone:347-237-7564
Mailing Address - Fax:
Practice Address - Street 1:516 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-3006
Practice Address - Country:US
Practice Address - Phone:347-237-7564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005973-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1851835342Medicaid