Provider Demographics
NPI:1376777011
Name:CHO, JAE BOME (LAC,OMD)
Entity Type:Individual
Prefix:MR
First Name:JAE
Middle Name:BOME
Last Name:CHO
Suffix:
Gender:M
Credentials:LAC,OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13011 NEWPORT AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3517
Mailing Address - Country:US
Mailing Address - Phone:714-730-7008
Mailing Address - Fax:
Practice Address - Street 1:13011 NEWPORT AVE
Practice Address - Street 2:STE 201
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3517
Practice Address - Country:US
Practice Address - Phone:714-730-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10607171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist