Provider Demographics
NPI:1912262387
Name:DONGWON ACUPUNCTURE LTD
Entity type:Organization
Organization Name:DONGWON ACUPUNCTURE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-938-9521
Mailing Address - Street 1:1600 W DEMPSTER ST
Mailing Address - Street 2:204
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1109
Mailing Address - Country:US
Mailing Address - Phone:224-938-9521
Mailing Address - Fax:224-938-9522
Practice Address - Street 1:1600 W DEMPSTER ST
Practice Address - Street 2:204
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1109
Practice Address - Country:US
Practice Address - Phone:224-938-9521
Practice Address - Fax:224-938-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000803302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001Medicaid
IL011335Medicare Oscar/Certification
IL001Medicaid
IL2778778900Medicare NSC
IL12Medicare PIN