Provider Demographics
NPI:1326182627
Name:YOM, JONG SUK (DC, LAC)
Entity Type:Individual
Prefix:
First Name:JONG SUK
Middle Name:
Last Name:YOM
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15609 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5033
Mailing Address - Country:US
Mailing Address - Phone:718-888-9900
Mailing Address - Fax:718-321-1459
Practice Address - Street 1:15609 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5033
Practice Address - Country:US
Practice Address - Phone:718-888-9900
Practice Address - Fax:718-321-1459
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009478111N00000X
NY001520171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07153Medicare ID - Type Unspecified
NYU80254Medicare UPIN