Provider Demographics
NPI:1346573847
Name:SHIN, KEVIN DAESU (LAC, PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAESU
Last Name:SHIN
Suffix:
Gender:M
Credentials:LAC, PHD
Other - Prefix:DR
Other - First Name:DAE
Other - Middle Name:SU
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, PHD
Mailing Address - Street 1:706A N REILLY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5619
Mailing Address - Country:US
Mailing Address - Phone:910-868-8865
Mailing Address - Fax:
Practice Address - Street 1:706A N REILLY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5619
Practice Address - Country:US
Practice Address - Phone:910-868-8865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202171100000X
CA4641171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$OtherSSN ID.