Provider Demographics
NPI:1710296389
Name:CHUNG, MINA (LAC)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 WILSHIRE BLVD #328
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010
Mailing Address - Country:US
Mailing Address - Phone:213-389-5902
Mailing Address - Fax:
Practice Address - Street 1:3545 WILSHIRE BLVD #328
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010
Practice Address - Country:US
Practice Address - Phone:213-389-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10828171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC10828OtherACUPUNCTURE