Provider Demographics
NPI:1346547783
Name:TAE, CHANG YONG (DC)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:YONG
Last Name:TAE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 FOOTHILL BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2771
Mailing Address - Country:US
Mailing Address - Phone:818-541-6733
Mailing Address - Fax:818-541-6723
Practice Address - Street 1:3043 FOOTHILL BLVD STE 6
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-2771
Practice Address - Country:US
Practice Address - Phone:818-541-6733
Practice Address - Fax:818-541-6723
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU76983Medicare UPIN