Provider Demographics
NPI:1487826640
Name:BAE, SOO J (LAC PHD)
Entity Type:Individual
Prefix:DR
First Name:SOO
Middle Name:J
Last Name:BAE
Suffix:
Gender:F
Credentials:LAC PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S BEACH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-6366
Mailing Address - Country:US
Mailing Address - Phone:562-902-1223
Mailing Address - Fax:
Practice Address - Street 1:1201 S BEACH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-6366
Practice Address - Country:US
Practice Address - Phone:562-902-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11980171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist