Provider Demographics
NPI:1407225113
Name:KOO, JA HYUNG
Entity type:Individual
Prefix:
First Name:JA HYUNG
Middle Name:
Last Name:KOO
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 1:817 W WILSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1649
Mailing Address - Country:US
Mailing Address - Phone:213-435-0665
Mailing Address - Fax:714-449-1399
Practice Address - Street 1:817 W WILSHIRE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1649
Practice Address - Country:US
Practice Address - Phone:213-435-0665
Practice Address - Fax:714-449-1399
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16434171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist