Basic Information
| Provider Information | |||||||||
| NPI: | 1518519313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHO | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1708 WALNUT AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908132431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625912324 | ||||||||
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| Practice Location | |||||||||
| Address1: | 679 S NEW HAMPSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900051355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136390299 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 171M00000X | 01 | CA | PACIFIC CLINICS | OTHER |