Provider Demographics
NPI:1841524881
Name:KYUNG SAN ACUPUNCTURE CLINIC
Entity type:Organization
Organization Name:KYUNG SAN ACUPUNCTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ACUPUNCTURIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAEGYOO
Authorized Official - Middle Name:
Authorized Official - Last Name:RYOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-380-0853
Mailing Address - Street 1:3030 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 202-203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6501
Mailing Address - Country:US
Mailing Address - Phone:213-380-0853
Mailing Address - Fax:213-380-0954
Practice Address - Street 1:3030 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 202-203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6501
Practice Address - Country:US
Practice Address - Phone:213-380-0853
Practice Address - Fax:213-380-0954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9854261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386880169Medicare PIN