Provider Demographics
NPI:1437205309
Name:YI, SUNG S (LAC)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:S
Last Name:YI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-1331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:273 I U WILLETS RD
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-2217
Practice Address - Country:US
Practice Address - Phone:516-873-7966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001405171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist