Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | CL1788 | CA |
Y | 156FX1800X | Optician | SL5735 | CA |
NPI | 1356628846 |
---|---|
Provider Name | Hae Jung Moon |
First Address | Torrance, CA 90505-5303 |
Second Address | Torrance, CA 90505-5303 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2011 |
Last Update Date | 10/11/2011 |