Provider Demographics
NPI:1255961850
Name:JANG, BONG SU (DPT)
Entity type:Individual
Prefix:
First Name:BONG SU
Middle Name:
Last Name:JANG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E AVENIDA PICO STE M
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3800
Mailing Address - Country:US
Mailing Address - Phone:949-245-6581
Mailing Address - Fax:
Practice Address - Street 1:415 E AVENIDA PICO STE M
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3800
Practice Address - Country:US
Practice Address - Phone:949-245-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist