Provider Demographics
NPI:1841744497
Name:SON, SE JIN (DPT)
Entity Type:Individual
Prefix:
First Name:SE JIN
Middle Name:
Last Name:SON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 BEACH BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2840
Mailing Address - Country:US
Mailing Address - Phone:657-255-4252
Mailing Address - Fax:657-255-4258
Practice Address - Street 1:6301 BEACH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:657-255-4252
Practice Address - Fax:657-255-4258
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296053225100000X
GAPT012336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA334934Medicaid