Healthcare Provider Details

I. General information

NPI: 1114337979
Provider Name (Legal Business Name): HENRY JOHN CHANG LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 AVENIDA DE LA PLAYA STE C
LA JOLLA CA
92037-3216
US

IV. Provider business mailing address

5694 MISSION CENTER RD STE 602 BOX 259
SAN DIEGO CA
92108-4355
US

V. Phone/Fax

Practice location:
  • Phone: 310-800-7927
  • Fax:
Mailing address:
  • Phone: 310-800-7927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: