Provider Demographics
NPI:1114046208
Name:CHUNG, HENRY KYUNGMO (L,AC)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:KYUNGMO
Last Name:CHUNG
Suffix:
Gender:M
Credentials:L,AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5953 BUFORD HWY NE
Mailing Address - Street 2:201
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1375
Mailing Address - Country:US
Mailing Address - Phone:770-457-8947
Mailing Address - Fax:770-457-8964
Practice Address - Street 1:5953 BUFORD HWY NE
Practice Address - Street 2:# 201
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1375
Practice Address - Country:US
Practice Address - Phone:770-457-8947
Practice Address - Fax:770-457-8964
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA#18171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist