Basic Information
Provider Information
NPI: 1003004946
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MOON
FirstName: EDDIE
MiddleName: JOOHYUN
NamePrefix:  
NameSuffix:  
Credential: DAOM, L.AC.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: MOON
OtherFirstName: JOO HYUN
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: DAOM, L.AC.
OtherLastNameType: 1
Mailing Information
Address1: 758 E COLORADO BLVD
Address2: STE.201
City: PASADENA
State: CA
PostalCode: 911012127
CountryCode: US
TelephoneNumber: 2132683007
FaxNumber:  
Practice Location
Address1: 758 E COLORADO BLVD
Address2: STE.201
City: PASADENA
State: CA
PostalCode: 911012127
CountryCode: US
TelephoneNumber: 2132683007
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/04/2007
LastUpdateDate: 03/19/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171100000XAC 11179CAY Other Service ProvidersAcupuncturist 

No ID Information.


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