Provider Demographics
NPI:1396508925
Name:SHIN, PETER JEE CHUL
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JEE CHUL
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-1107 KOOLANI DR APT 228
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-5917
Mailing Address - Country:US
Mailing Address - Phone:808-221-5457
Mailing Address - Fax:
Practice Address - Street 1:94-801 FARRINGTON HWY STE W2
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3149
Practice Address - Country:US
Practice Address - Phone:808-680-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4090225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist