Healthcare Provider Details

I. General information

NPI: 1023249943
Provider Name (Legal Business Name): JIN WANG LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 07/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S ROSEMEAD BLVD #Q6
PASADENA CA
91107-3960
US

IV. Provider business mailing address

110 S ROSEMEAD BLVD #Q6
PASADENA CA
91107-3960
US

V. Phone/Fax

Practice location:
  • Phone: 626-927-8185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC9387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: