Provider Demographics
NPI:1902968654
Name:CHO, BON HOAN (LAC)
Entity Type:Individual
Prefix:
First Name:BON
Middle Name:HOAN
Last Name:CHO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11540 SANTA MONICA BLVD
Mailing Address - Street 2:#203
Mailing Address - City:WEST LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7905
Mailing Address - Country:US
Mailing Address - Phone:310-268-0268
Mailing Address - Fax:310-914-7633
Practice Address - Street 1:11540 SANTA MONICA BLVD
Practice Address - Street 2:#203
Practice Address - City:WEST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7905
Practice Address - Country:US
Practice Address - Phone:310-268-0268
Practice Address - Fax:310-914-7633
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 5220171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0052200Medicaid