Healthcare Provider Details

I. General information

NPI: 1073129797
Provider Name (Legal Business Name): BONGCHOL YI LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 W BEVERLY BLVD
MONTEBELLO CA
90640-4154
US

IV. Provider business mailing address

1437 W BEVERLY BLVD
MONTEBELLO CA
90640-4154
US

V. Phone/Fax

Practice location:
  • Phone: 323-887-7575
  • Fax: 310-362-3475
Mailing address:
  • Phone: 323-887-7575
  • Fax: 310-362-3475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number83912
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC18939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: