=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346573847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN DAESU SHIN L.AC., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2009
-----------------------------------------------------
Last Update Date | 09/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 706A N REILLY RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-5619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-868-8865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 706A N REILLY RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-5619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-868-8865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 202
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 4641
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------