Provider Demographics
NPI:1548594104
Name:SUH, GLEN (LAC)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:
Last Name:SUH
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 1:1039 FOOTHILL BLVD # A
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-3249
Mailing Address - Country:US
Mailing Address - Phone:818-288-6604
Mailing Address - Fax:
Practice Address - Street 1:1039 FOOTHILL BLVD # A
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-3249
Practice Address - Country:US
Practice Address - Phone:818-288-6604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12916171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist