Provider Demographics
NPI:1972048346
Name:YOO, MINJAE
Entity Type:Individual
Prefix:
First Name:MINJAE
Middle Name:
Last Name:YOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 15TH STREET 1ST FLOOR
Mailing Address - Street 2:
Mailing Address - City:FORTLEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:551-655-4284
Mailing Address - Fax:
Practice Address - Street 1:1209 15TH ST FL 1
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-1707
Practice Address - Country:US
Practice Address - Phone:551-655-4284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012790111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor