Healthcare Provider Details

I. General information

NPI: 1922578780
Provider Name (Legal Business Name): HYUIWON SARA SUH LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SHERIDAN RD
FULLERTON CA
92833-1422
US

IV. Provider business mailing address

2720 SHERIDAN RD
FULLERTON CA
92833-1422
US

V. Phone/Fax

Practice location:
  • Phone: 714-616-2200
  • Fax:
Mailing address:
  • Phone: 714-616-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC18210
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTCH54797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: