Healthcare Provider Details

I. General information

NPI: 1699952028
Provider Name (Legal Business Name): SUK YOUNG SHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 SPRUCE ST STE P
RIVERSIDE CA
92507-7421
US

IV. Provider business mailing address

19923 MEADOWS CT
CERRITOS CA
90703-7854
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-8167
  • Fax:
Mailing address:
  • Phone: 714-225-8198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC11280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: