Provider Demographics
NPI:1447801626
Name:HAN, DONG GWON (DC, DAOM, LAC)
Entity Type:Individual
Prefix:
First Name:DONG GWON
Middle Name:
Last Name:HAN
Suffix:
Gender:M
Credentials:DC, DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 S WESTERN AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2376
Mailing Address - Country:US
Mailing Address - Phone:310-935-8703
Mailing Address - Fax:
Practice Address - Street 1:1144 S WESTERN AVE STE 207
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2376
Practice Address - Country:US
Practice Address - Phone:310-935-8703
Practice Address - Fax:213-722-5025
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36749111N00000X
CA12935171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty