Provider Demographics
NPI:1518397074
Name:BAE, JAE WON
Entity Type:Individual
Prefix:
First Name:JAE WON
Middle Name:
Last Name:BAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 KEENE RD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-8683
Mailing Address - Country:US
Mailing Address - Phone:949-422-7008
Mailing Address - Fax:509-628-9976
Practice Address - Street 1:134 KEENE RD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-8683
Practice Address - Country:US
Practice Address - Phone:509-628-9966
Practice Address - Fax:509-628-9976
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15656171100000X
WAAC60830326171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist