Provider Demographics
NPI:1487833398
Name:CHANG, KI HYUN (LAC)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:HYUN
Last Name:CHANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1870 WINDJAMMER DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8658
Mailing Address - Country:US
Mailing Address - Phone:651-730-5494
Mailing Address - Fax:651-430-0900
Practice Address - Street 1:14791 60TH ST N STE 6
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6382
Practice Address - Country:US
Practice Address - Phone:651-430-3600
Practice Address - Fax:651-430-0900
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1408171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist