Provider Demographics
NPI:1396016119
Name:KO, SANG CHUL (LMP)
Entity Type:Individual
Prefix:MR
First Name:SANG
Middle Name:CHUL
Last Name:KO
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8451 S D ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-6450
Mailing Address - Country:US
Mailing Address - Phone:253-389-9007
Mailing Address - Fax:
Practice Address - Street 1:8451 S D ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-6450
Practice Address - Country:US
Practice Address - Phone:253-389-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60253959225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist