MEDICARE: JONG CHANG LAC, OMD, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC12455	CA

General Provider Information

NPI Number	:	1427364918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONG CHANG LAC, OMD, PHD

Provider Business Mailing Address
First Line	:	966 S WESTERN AVE
Second Line	:	SUITE #206
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-1013
Country	:	US
Telephone Number	:	323-735-1905
Fax Number	:	323-735-1905

Provider Business Practice Location Address
First Line	:	966 S WESTERN AVE
Second Line	:	SUITE #206
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-1013
Country	:	US
Telephone Number	:	323-735-1905
Fax Number	:	323-735-1905

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	08/23/2010

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