=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104150077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEUNGMOOK SHIN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2009
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 WELSH RD # F2
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-647-2188
-----------------------------------------------------
Fax | 215-647-2943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 WELSH RD # F2
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-647-2188
-----------------------------------------------------
Fax | 215-647-2943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC010156
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------