Provider Demographics
NPI:1134390974
Name:KWAK, TAE HOON (LAC)
Entity type:Individual
Prefix:MR
First Name:TAE
Middle Name:HOON
Last Name:KWAK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:163 S FAIRFAX
Mailing Address - Street 2:#2
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036
Mailing Address - Country:US
Mailing Address - Phone:323-933-6490
Mailing Address - Fax:323-933-6590
Practice Address - Street 1:163 S FAIRFAX AVE
Practice Address - Street 2:#2
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2164
Practice Address - Country:US
Practice Address - Phone:323-933-6490
Practice Address - Fax:323-933-6590
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11721171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist