Provider Demographics
NPI:1265935514
Name:JEONG, PYENGSOO
Entity type:Individual
Prefix:
First Name:PYENGSOO
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14916 LEMOLI AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-3420
Mailing Address - Country:US
Mailing Address - Phone:562-403-3322
Mailing Address - Fax:
Practice Address - Street 1:2316 ARTESIA BLVD STE E
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3187
Practice Address - Country:US
Practice Address - Phone:562-403-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8778171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist