Provider Demographics
NPI:1669796330
Name:KO, HAE JUNG (LAC)
Entity type:Individual
Prefix:
First Name:HAE
Middle Name:JUNG
Last Name:KO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8590 PELHAM RD
Mailing Address - Street 2:#13
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5786
Mailing Address - Country:US
Mailing Address - Phone:864-286-0777
Mailing Address - Fax:
Practice Address - Street 1:8590 PELHAM RD
Practice Address - Street 2:#13
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5786
Practice Address - Country:US
Practice Address - Phone:864-286-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist