Basic Information
Provider Information
NPI: 1700952926
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHUNG
FirstName: ETTA
MiddleName: LIM
NamePrefix: MRS.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1975 LONG BEACH BLVD
Address2:  
City: LONG BEACH
State: CA
PostalCode: 908065501
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1975 LONG BEACH BLVD
Address2:  
City: LONG BEACH
State: CA
PostalCode: 908065501
CountryCode: US
TelephoneNumber: 5625999401
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/28/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225400000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner 

No ID Information.


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