Provider Demographics
NPI:1154644581
Name:SHIN, JEONG SIK (LAC)
Entity Type:Individual
Prefix:
First Name:JEONG
Middle Name:SIK
Last Name:SHIN
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 1:809 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-1522
Mailing Address - Country:US
Mailing Address - Phone:213-739-0855
Mailing Address - Fax:213-739-0838
Practice Address - Street 1:809 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1522
Practice Address - Country:US
Practice Address - Phone:213-739-0855
Practice Address - Fax:213-739-0838
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12099171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist