Provider Demographics
NPI:1437781366
Name:EAGLE CLASSIC WELLNESS INC
Entity Type:Organization
Organization Name:EAGLE CLASSIC WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOCK JU
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-229-2721
Mailing Address - Street 1:1914 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-1537
Mailing Address - Country:US
Mailing Address - Phone:909-229-2721
Mailing Address - Fax:
Practice Address - Street 1:1914 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1537
Practice Address - Country:US
Practice Address - Phone:909-229-2721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLE CLASSIC WELLNESS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty