Healthcare Provider Details

I. General information

NPI: 1639920036
Provider Name (Legal Business Name): JIWON BAE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 SAWTELLE BLVD
LOS ANGELES CA
90066-1408
US

IV. Provider business mailing address

14642 NEWPORT AVE STE 105
TUSTIN CA
92780-6058
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-9018
  • Fax: 310-390-0868
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number36057
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number20011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: