Provider Demographics
NPI:1831474410
Name:CHONG, DAE-EIL
Entity Type:Individual
Prefix:
First Name:DAE-EIL
Middle Name:
Last Name:CHONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20601 W PAOLI LANE
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:CA
Mailing Address - Zip Code:95736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 YPAO RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3701
Practice Address - Country:US
Practice Address - Phone:671-646-8881
Practice Address - Fax:671-646-1292
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38707225100000X
NY033363225100000X
GUPT-156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist