Healthcare Provider Details

I. General information

NPI: 1356857387
Provider Name (Legal Business Name): EDWARD JONGEUN SHIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE SUITE 2002
RIVERSIDE CA
92507
US

IV. Provider business mailing address

136 N LOHRUM LN
ANAHEIM CA
92807-3114
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7320
  • Fax: 951-955-7203
Mailing address:
  • Phone: 951-955-7320
  • Fax: 951-955-7203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number40646
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: