Provider Demographics
NPI:1083968697
Name:MOON, BYUNGHEON (LAC)
Entity Type:Individual
Prefix:
First Name:BYUNGHEON
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:CLARK
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:5241 LINCOLN AVE. STE C1
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630
Mailing Address - Country:US
Mailing Address - Phone:714-980-1364
Mailing Address - Fax:714-761-7934
Practice Address - Street 1:5241 LINCOLN AVE. STE C1
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630
Practice Address - Country:US
Practice Address - Phone:714-980-1364
Practice Address - Fax:714-761-7934
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15073171100000X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist