Healthcare Provider Details

I. General information

NPI: 1386880169
Provider Name (Legal Business Name): JAY RYU L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2008
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 W OLYMPIC BLVD 202-203
LOS ANGELES CA
90006-6501
US

IV. Provider business mailing address

3030 W OLYMPIC BLVD 202-203
LOS ANGELES CA
90006-6501
US

V. Phone/Fax

Practice location:
  • Phone: 213-380-0853
  • Fax: 213-380-0954
Mailing address:
  • Phone: 213-380-0853
  • Fax: 213-380-0954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC9854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: