Basic Information
| Provider Information | |||||||||
| NPI: | 1235304999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOO | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | HYUN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1636 W GARDENA BLVD | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902474725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107683028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 680 S WILTON PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900053200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133657400 | ||||||||
| FaxNumber: | 2133831280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.