Provider Demographics
NPI:1184002982
Name:WON, DAE IL (LAC)
Entity Type:Individual
Prefix:
First Name:DAE IL
Middle Name:
Last Name:WON
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 1:3053 W OLYMPIC BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2558
Mailing Address - Country:US
Mailing Address - Phone:213-483-6688
Mailing Address - Fax:213-483-6636
Practice Address - Street 1:3053 W OLYMPIC BLVD STE 301
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2558
Practice Address - Country:US
Practice Address - Phone:213-483-6688
Practice Address - Fax:213-483-6636
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA15920171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist