Provider Demographics
NPI:1699046441
Name:RO, JAE GON (LAC)
Entity type:Individual
Prefix:MR
First Name:JAE GON
Middle Name:
Last Name:RO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:JAE GON
Other - Middle Name:
Other - Last Name:RO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:301 S WESTERN AVE
Mailing Address - Street 2:#205&206
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3831
Mailing Address - Country:US
Mailing Address - Phone:213-739-2236
Mailing Address - Fax:
Practice Address - Street 1:301 S WESTERN AVE
Practice Address - Street 2:#205&206
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3831
Practice Address - Country:US
Practice Address - Phone:213-739-2236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13215171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist