Healthcare Provider Details

I. General information

NPI: 1124931795
Provider Name (Legal Business Name): SO JIN YOO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11872 ZACH DR
SAN DIEGO CA
92128-4927
US

IV. Provider business mailing address

11872 ZACH DR
SAN DIEGO CA
92128-4927
US

V. Phone/Fax

Practice location:
  • Phone: 832-998-3152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: