MEDICARE: FUN LAC

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	AC13570	CA

General Provider Information

NPI Number	:	1538444971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUN LAC

Provider Business Mailing Address
First Line	:	9337 VERVAIN ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-3571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9337 VERVAIN ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-3571
Country	:	US
Telephone Number	:	626-271-6671
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SHENFANG SHARON CHANG
Credential	:
Telephone Number	:	626-271-6671

Provider Enumeration Date	:	10/17/2011
Last Update Date	:	10/17/2011

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