Healthcare Provider Details

I. General information

NPI: 1063940435
Provider Name (Legal Business Name): JASON VINCENT BUKICH MSAOM L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24586 VIA DEL ORO
LAGUNA NIGUEL CA
92677-7605
US

IV. Provider business mailing address

24586 VIA DEL ORO
LAGUNA NIGUEL CA
92677-7605
US

V. Phone/Fax

Practice location:
  • Phone: 949-735-9981
  • Fax:
Mailing address:
  • Phone: 949-735-9981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: