Healthcare Provider Details

I. General information

NPI: 1598583650
Provider Name (Legal Business Name): RYAN JUNG HYUN BACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BROADWAY STE 301
TACOMA WA
98402-4454
US

IV. Provider business mailing address

1145 SW 352ND ST
FEDERAL WAY WA
98023-6921
US

V. Phone/Fax

Practice location:
  • Phone: 253-671-9909
  • Fax:
Mailing address:
  • Phone: 253-508-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: