Provider Demographics
NPI:1891225595
Name:JI, TAE HOON (LAC)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:HOON
Last Name:JI
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 1:1933 W MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-6930
Mailing Address - Country:US
Mailing Address - Phone:480-730-4991
Mailing Address - Fax:480-946-3366
Practice Address - Street 1:1933 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6930
Practice Address - Country:US
Practice Address - Phone:480-730-4991
Practice Address - Fax:480-946-3366
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1074171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ283OtherACUPUNCTURE