Healthcare Provider Details

I. General information

NPI: 1447647490
Provider Name (Legal Business Name): LAURA WANG LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA PEI FEI FAN MSAOM

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 S HACIENDA BLVD #201A
HACIENDA HEIGHTS CA
91745-6305
US

IV. Provider business mailing address

PO BOX 5452
DIAMOND BAR CA
91765-7452
US

V. Phone/Fax

Practice location:
  • Phone: 626-905-1833
  • Fax:
Mailing address:
  • Phone: 626-905-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC16402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: