Provider Demographics
NPI:1760787345
Name:SHIN, BONJA (LAC)
Entity Type:Individual
Prefix:
First Name:BONJA
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 S WESTERN AVE B2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2366
Mailing Address - Country:US
Mailing Address - Phone:213-283-6166
Mailing Address - Fax:213-402-2453
Practice Address - Street 1:1134 S WESTERN AVE B2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2366
Practice Address - Country:US
Practice Address - Phone:213-283-6166
Practice Address - Fax:213-402-2453
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11329171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC11329OtherACUPUNCTURE