Provider Demographics
NPI:1043664436
Name:LILY JEI-HO CHANG
Entity type:Organization
Organization Name:LILY JEI-HO CHANG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:JEI-HO
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:425-286-7018
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:12710 102ND AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2847
Practice Address - Country:US
Practice Address - Phone:425-286-7018
Practice Address - Fax:888-431-8819
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LILY JEI-HO CHANG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60454183332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site