Provider Demographics
NPI:1184988107
Name:MOON, SANGROK (DC, LAC)
Entity type:Individual
Prefix:
First Name:SANGROK
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 LEMOINE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6210
Mailing Address - Country:US
Mailing Address - Phone:201-559-5307
Mailing Address - Fax:201-351-4787
Practice Address - Street 1:2460 LEMOINE AVE STE 203
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6210
Practice Address - Country:US
Practice Address - Phone:201-559-5307
Practice Address - Fax:201-351-4787
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00648800111N00000X
NJ25MZ00081300171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractor