Provider Demographics
NPI:1821844317
Name:SHIN, SEUNG WON
Entity type:Individual
Prefix:
First Name:SEUNG WON
Middle Name:
Last Name:SHIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13346 SAVANNA
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-9142
Mailing Address - Country:US
Mailing Address - Phone:714-552-6650
Mailing Address - Fax:
Practice Address - Street 1:14451 CHAMBERS RD
Practice Address - Street 2:#100
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6971
Practice Address - Country:US
Practice Address - Phone:949-237-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist