Provider Demographics
NPI:1902083595
Name:HAN, JOONG GU (LAC)
Entity Type:Individual
Prefix:
First Name:JOONG
Middle Name:GU
Last Name:HAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5115
Mailing Address - Country:US
Mailing Address - Phone:909-886-4020
Mailing Address - Fax:
Practice Address - Street 1:53116 TROPICAL STREET
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532
Practice Address - Country:US
Practice Address - Phone:213-999-3176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11976171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist