Provider Demographics
NPI:1477838068
Name:JIN, SANGSIK (LAC)
Entity Type:Individual
Prefix:
First Name:SANGSIK
Middle Name:
Last Name:JIN
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 1:15901 HAWTHORNE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2766
Mailing Address - Country:US
Mailing Address - Phone:310-701-1077
Mailing Address - Fax:
Practice Address - Street 1:15901 HAWTHORNE BLVD STE 115
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2766
Practice Address - Country:US
Practice Address - Phone:310-701-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2023-01-31
Deactivation Date:2022-10-07
Deactivation Code:
Reactivation Date:2023-01-25
Provider Licenses
StateLicense IDTaxonomies
CAAC13672171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC13672OtherACUPUNCTURE