Healthcare Provider Details

I. General information

NPI: 1518397074
Provider Name (Legal Business Name): JAE WON BAE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 KEENE RD
RICHLAND WA
99352-8683
US

IV. Provider business mailing address

134 KEENE RD
RICHLAND WA
99352-8683
US

V. Phone/Fax

Practice location:
  • Phone: 509-628-9966
  • Fax: 509-628-9976
Mailing address:
  • Phone: 949-422-7008
  • Fax: 509-628-9976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15656
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60830326
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: