MEDICARE: BONJA SHIN 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	AC11329	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AC11329	OTHER	CA	ACUPUNCTURE

General Provider Information

NPI Number	:	1760787345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONJA SHIN LAC

Provider Business Mailing Address
First Line	:	1134 S WESTERN AVE B2
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2366
Country	:	US
Telephone Number	:	213-283-6166
Fax Number	:	213-402-2453

Provider Business Practice Location Address
First Line	:	1134 S WESTERN AVE B2
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2366
Country	:	US
Telephone Number	:	213-283-6166
Fax Number	:	213-402-2453

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

Provider Enumeration Date	:	01/13/2011
Last Update Date	:	01/13/2011

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Directions to “ BONJA SHIN LAC” Practice Location

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