Provider Demographics
NPI:1538524145
Name:CHUNG, JIN K (ATC, CES)
Entity type:Individual
Prefix:
First Name:JIN K
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:ATC, CES
Other - Prefix:
Other - First Name:PABLO
Other - Middle Name:
Other - Last Name:CHUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC, CES
Mailing Address - Street 1:18400 AVALON BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18400 AVALON BLVD
Practice Address - Street 2:STE 200
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-2172
Practice Address - Country:US
Practice Address - Phone:310-738-3099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-24
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer