Provider Demographics
NPI:1538586490
Name:BEACON EAST ASIAN MEDICINE
Entity type:Organization
Organization Name:BEACON EAST ASIAN MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF ACUPUNCTURE ORIENTAL MED.
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:YONCHAE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:213-448-4254
Mailing Address - Street 1:96 W VILLA ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3343
Mailing Address - Country:US
Mailing Address - Phone:213-448-4254
Mailing Address - Fax:626-796-7187
Practice Address - Street 1:379 W BELLEVUE DR
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1833
Practice Address - Country:US
Practice Address - Phone:213-448-4254
Practice Address - Fax:626-796-7187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15193305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC15193OtherLICENSED ACUPUNCTURIST
CA64OtherACUPUNCTURE