Provider Demographics
NPI:1316979677
Name:SHIN, YOUNG SE (L AC)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:SE
Last Name:SHIN
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:9828 GARDEN GROVE BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1639
Mailing Address - Country:US
Mailing Address - Phone:714-530-3550
Mailing Address - Fax:714-530-3556
Practice Address - Street 1:9828 GARDEN GROVE BLVD
Practice Address - Street 2:STE 106
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1639
Practice Address - Country:US
Practice Address - Phone:714-530-3550
Practice Address - Fax:714-530-3556
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC0001690171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA0001690OtherBLUE SHIELD
CAAC0001690Medicaid