Provider Demographics
NPI:1376250720
Name:BACK, JUNGHA
Entity Type:Individual
Prefix:
First Name:JUNGHA
Middle Name:
Last Name:BACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1506
Mailing Address - Country:US
Mailing Address - Phone:334-593-3932
Mailing Address - Fax:
Practice Address - Street 1:1726 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1506
Practice Address - Country:US
Practice Address - Phone:334-593-3932
Practice Address - Fax:334-593-7715
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL232077156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1225700230Medicaid
AL276390Medicaid