Provider Demographics
NPI:1134390842
Name:KOO, IRENE SORA (DAOM)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:SORA
Last Name:KOO
Suffix:
Gender:F
Credentials:DAOM
Other - Prefix:
Other - First Name:SO
Other - Middle Name:RA
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DAOM
Mailing Address - Street 1:715 N CENTRAL AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1286
Mailing Address - Country:US
Mailing Address - Phone:323-912-9200
Mailing Address - Fax:
Practice Address - Street 1:715 N CENTRAL AVE STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1286
Practice Address - Country:US
Practice Address - Phone:323-912-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7281171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist