Provider Demographics
NPI:1740806538
Name:SO CAL INTEGRATED MEDICAL GROUP
Entity Type:Organization
Organization Name:SO CAL INTEGRATED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEUNG WAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HONG
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:213-245-8480
Mailing Address - Street 1:901 S FLOWER ST UNIT 613
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2298
Mailing Address - Country:US
Mailing Address - Phone:213-245-8480
Mailing Address - Fax:
Practice Address - Street 1:133 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4878
Practice Address - Country:US
Practice Address - Phone:213-245-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty