Provider Demographics
NPI:1689835530
Name:BAE, JOSHUA (LAC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BAE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:SANG SUK
Other - Middle Name:
Other - Last Name:BAE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:14642 NEWPORT AVE.
Mailing Address - Street 2:#105
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:323-735-5011
Mailing Address - Fax:323-735-5630
Practice Address - Street 1:14642 NEWPORT AVE.
Practice Address - Street 2:#105
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:323-735-5011
Practice Address - Fax:323-735-5630
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12071171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC12071OtherAC12071