Healthcare Provider Details

I. General information

NPI: 1255673182
Provider Name (Legal Business Name): XIAO YUAN QIU LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WATERWORKS WAY STE 305
IRVINE CA
92618-3174
US

IV. Provider business mailing address

113 WATERWORKS WAY STE 305
IRVINE CA
92618-3174
US

V. Phone/Fax

Practice location:
  • Phone: 949-348-1711
  • Fax: 949-348-1713
Mailing address:
  • Phone: 949-348-1711
  • Fax: 949-348-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 4172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: