Provider Demographics
NPI:1851591507
Name:IM, SOO HYUCK (OMD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:HYUCK
Last Name:IM
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 ORANGETHORPE AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1338
Mailing Address - Country:US
Mailing Address - Phone:714-562-0100
Mailing Address - Fax:714-562-0120
Practice Address - Street 1:6110 ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1338
Practice Address - Country:US
Practice Address - Phone:714-562-0100
Practice Address - Fax:714-562-0120
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5777171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist