Provider Demographics
NPI:1912272022
Name:JI, MIN SOO (LAC)
Entity Type:Individual
Prefix:
First Name:MIN
Middle Name:SOO
Last Name:JI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 115TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-1059
Mailing Address - Country:US
Mailing Address - Phone:347-882-7805
Mailing Address - Fax:718-321-1442
Practice Address - Street 1:3830 PARSONS BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5843
Practice Address - Country:US
Practice Address - Phone:718-321-0205
Practice Address - Fax:718-321-1442
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004777171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist