Provider Demographics
NPI:1063717650
Name:JEON, WILLIAM TAE GWEON (ACUPUNCTURIST)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TAE GWEON
Last Name:JEON
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 W OLYMPIC BLVD STE 308
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2279
Mailing Address - Country:US
Mailing Address - Phone:213-249-4124
Mailing Address - Fax:
Practice Address - Street 1:2140 W OLYMPIC BLVD STE 308
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2279
Practice Address - Country:US
Practice Address - Phone:213-249-4124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11870171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist