Provider Demographics
NPI:1629182985
Name:SOO C SHIN
Entity Type:Organization
Organization Name:SOO C SHIN
Other - Org Name:OLYMPIC MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOO
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-389-5231
Mailing Address - Street 1:3003 W OLYMPIC BLVD
Mailing Address - Street 2:205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3003 W OLYMPIC BLVD
Practice Address - Street 2:205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6511
Practice Address - Country:US
Practice Address - Phone:213-389-5231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1241810001Medicare ID - Type Unspecified