Provider Demographics
NPI:1558582635
Name:JUNG, CHANG SUP (AC)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:SUP
Last Name:JUNG
Suffix:
Gender:M
Credentials:AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-5503
Mailing Address - Country:US
Mailing Address - Phone:562-596-2257
Mailing Address - Fax:714-638-9780
Practice Address - Street 1:1920 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-5503
Practice Address - Country:US
Practice Address - Phone:562-596-2257
Practice Address - Fax:714-638-9780
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5413171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist