Provider Demographics
NPI:1336284157
Name:SHIN, JAE RYONG
Entity Type:Individual
Prefix:
First Name:JAE RYONG
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 FRUITLAND DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-1504
Mailing Address - Country:US
Mailing Address - Phone:760-758-9086
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY STE 206
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5736
Practice Address - Country:US
Practice Address - Phone:760-724-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator