Provider Demographics
NPI:1013424068
Name:KOO, DOMINIC JUNG SOO (PT)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JUNG SOO
Last Name:KOO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 KANUNU ST
Mailing Address - Street 2:APT 1404
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 E DESERT INN RD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3632
Practice Address - Country:US
Practice Address - Phone:702-294-7499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist