Provider Demographics
NPI:1609386408
Name:BAE, JIN HO (LAC)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:HO
Last Name:BAE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E THOUSAND OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-6009
Mailing Address - Country:US
Mailing Address - Phone:805-497-7631
Mailing Address - Fax:888-556-8420
Practice Address - Street 1:650 E THOUSAND OAKS BLVD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-6009
Practice Address - Country:US
Practice Address - Phone:805-497-7631
Practice Address - Fax:888-556-8420
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6059171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6059OtherACUPUNCTURE