Provider Demographics
NPI:1285065185
Name:JEON, EUNSANG (LAC)
Entity type:Individual
Prefix:
First Name:EUNSANG
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 BEACH BLVD
Mailing Address - Street 2:#102
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5730 BEACH BLVD
Practice Address - Street 2:#102
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2094
Practice Address - Country:US
Practice Address - Phone:714-522-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15516171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist