Provider Demographics
NPI:1487791737
Name:SHIN, YOUNG KYU (DC)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:KYU
Last Name:SHIN
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 1:9192 GARDEN GROVE BLVD
Mailing Address - Street 2:#A
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844
Mailing Address - Country:US
Mailing Address - Phone:714-636-3681
Mailing Address - Fax:714-636-3173
Practice Address - Street 1:9192 GARDEN GROVE BLVD
Practice Address - Street 2:#A
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844
Practice Address - Country:US
Practice Address - Phone:714-636-3681
Practice Address - Fax:714-636-3173
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC19603Medicare ID - Type Unspecified
T82734Medicare UPIN