Provider Demographics
NPI:1104150077
Name:SHIN, SEUNGMOOK (DC)
Entity type:Individual
Prefix:
First Name:SEUNGMOOK
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WELSH RD # F2
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3771
Mailing Address - Country:US
Mailing Address - Phone:215-647-2188
Mailing Address - Fax:215-647-2943
Practice Address - Street 1:1200 WELSH RD # F2
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-3771
Practice Address - Country:US
Practice Address - Phone:215-647-2188
Practice Address - Fax:215-647-2943
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010156111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA268736YNPQMedicaid