Provider Demographics
NPI:1356628846
Name:MOON, HAE JUNG (ABO, NCLE)
Entity Type:Individual
Prefix:
First Name:HAE JUNG
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:ABO, NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24228 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5303
Mailing Address - Country:US
Mailing Address - Phone:310-539-2449
Mailing Address - Fax:
Practice Address - Street 1:24228 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5303
Practice Address - Country:US
Practice Address - Phone:310-539-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL1788156FC0800X
CASL5735156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens