Provider Demographics
NPI:1063824290
Name:JI, DAEHWAN (LAC)
Entity Type:Individual
Prefix:
First Name:DAEHWAN
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 BERGEN BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2345
Mailing Address - Country:US
Mailing Address - Phone:201-469-6899
Mailing Address - Fax:201-461-7122
Practice Address - Street 1:460 BERGEN BLVD SUITE #304
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650
Practice Address - Country:US
Practice Address - Phone:201-469-6899
Practice Address - Fax:201-461-7122
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00075000171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist