Healthcare Provider Details

I. General information

NPI: 1871851675
Provider Name (Legal Business Name): SUSAN SHAO L.AC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9092 TALBERT AVE #10
FOUNTAIN VALLEY CA
92708-4452
US

IV. Provider business mailing address

9092 TALBERT AVE #10
FOUNTAIN VALLEY CA
92708-4452
US

V. Phone/Fax

Practice location:
  • Phone: 714-968-3325
  • Fax:
Mailing address:
  • Phone: 714-968-3325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC-2948
License Number StateCA

VIII. Authorized Official

Name: SUSAN SHAO
Title or Position: OFFICER PRESIDENT & SECRETARY
Credential: ACUPUNCTURIST
Phone: 714-968-3325