1790967289 NPI number — ALEXANDER YOUNG SOO SEO LAC PHD

Table of content: ALEXANDER YOUNG SOO SEO LAC PHD (NPI 1790967289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790967289 NPI number — ALEXANDER YOUNG SOO SEO LAC PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEO
Provider First Name:
ALEXANDER
Provider Middle Name:
YOUNG SOO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEO
Provider Other First Name:
YOUNGSOO
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790967289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 S HOBART BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90005-2702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-385-3304
Provider Business Mailing Address Fax Number:
212-487-2640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 S HOBART BL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90005-2702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-385-3304
Provider Business Practice Location Address Fax Number:
212-487-2640
Provider Enumeration Date:
11/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  4920 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)