Provider Demographics
NPI:1962672444
Name:SHIN, JOHN SANGHYUN (DISPENSER)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SANGHYUN
Last Name:SHIN
Suffix:
Gender:M
Credentials:DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PADDOCK CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-0819
Mailing Address - Country:US
Mailing Address - Phone:714-534-5678
Mailing Address - Fax:707-570-1367
Practice Address - Street 1:12902 BROOKHURST ST
Practice Address - Street 2:STE D
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4881
Practice Address - Country:US
Practice Address - Phone:714-534-5678
Practice Address - Fax:714-534-3114
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7331237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist