Provider Demographics
NPI:1457620593
Name:JOO, WAN BAE (DC)
Entity type:Individual
Prefix:MR
First Name:WAN
Middle Name:BAE
Last Name:JOO
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 1:3725 OLD NORCROSS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4333
Mailing Address - Country:US
Mailing Address - Phone:404-247-8103
Mailing Address - Fax:678-473-4810
Practice Address - Street 1:3725 OLD NORCROSS RD STE 100
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4333
Practice Address - Country:US
Practice Address - Phone:404-247-8103
Practice Address - Fax:678-473-4810
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008907111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor