Provider Demographics
NPI:1710431820
Name:PAE, HEEWON (LAC)
Entity Type:Individual
Prefix:
First Name:HEEWON
Middle Name:
Last Name:PAE
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 1:1720 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1441
Mailing Address - Country:US
Mailing Address - Phone:224-305-1588
Mailing Address - Fax:
Practice Address - Street 1:1576 N WINDSOR DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-4100
Practice Address - Country:US
Practice Address - Phone:224-305-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000554171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist