Basic Information
| Provider Information | |||||||||
| NPI: | 1649913914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | REBECCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5115 CIRCLE VISTA AVE | ||||||||
| Address2: | |||||||||
| City: | LA CRESCENTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912143016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136638036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1720 E CESAR E CHAVEZ AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232685000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2022 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.