Provider Demographics
NPI:1093244006
Name:CHUNG, BONGSILL
Entity Type:Individual
Prefix:
First Name:BONGSILL
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21209 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715
Mailing Address - Country:US
Mailing Address - Phone:562-405-4787
Mailing Address - Fax:
Practice Address - Street 1:1670 EAST 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:424-338-2366
Practice Address - Fax:310-223-0361
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357813163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care