Provider Demographics
NPI:1275688558
Name:EVERGREEN CERRITOS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EVERGREEN CERRITOS MEDICAL GROUP, INC.
Other - Org Name:DR. HUNG-CHUEN YEUNG CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HUNG-CHUEN
Authorized Official - Middle Name:
Authorized Official - Last Name:YEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-968-2442
Mailing Address - Street 1:15940 HALLIBURTON RD
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-3505
Mailing Address - Country:US
Mailing Address - Phone:626-968-2442
Mailing Address - Fax:626-968-1191
Practice Address - Street 1:15940 HALLIBURTON RD
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-3505
Practice Address - Country:US
Practice Address - Phone:626-968-2442
Practice Address - Fax:626-968-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056340Medicaid
CAW12048Medicare ID - Type Unspecified