Provider Demographics
NPI:1598406498
Name:AHN, JOO DONG (LAC)
Entity Type:Individual
Prefix:
First Name:JOO DONG
Middle Name:
Last Name:AHN
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 1:46265 PALOMINO RD
Mailing Address - Street 2:
Mailing Address - City:AGUANGA
Mailing Address - State:CA
Mailing Address - Zip Code:92536-9515
Mailing Address - Country:US
Mailing Address - Phone:714-883-3305
Mailing Address - Fax:
Practice Address - Street 1:36945 COOK ST STE 103
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6077
Practice Address - Country:US
Practice Address - Phone:800-385-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5018171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty