Provider Demographics
NPI:1043733454
Name:SHIN, SEUNGTAE
Entity Type:Individual
Prefix:MR
First Name:SEUNGTAE
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 W 7TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-1454
Mailing Address - Country:US
Mailing Address - Phone:213-377-4249
Mailing Address - Fax:
Practice Address - Street 1:3050 W 7TH ST STE 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1454
Practice Address - Country:US
Practice Address - Phone:213-377-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16605171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist