Healthcare Provider Details

I. General information

NPI: 1134501521
Provider Name (Legal Business Name): VIGNETTE CHING MTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

573 S LAKE AVE
PASADENA CA
91101-3522
US

IV. Provider business mailing address

573 S LAKE AVE STE 6
PASADENA CA
91101-3593
US

V. Phone/Fax

Practice location:
  • Phone: 626-235-0591
  • Fax:
Mailing address:
  • Phone: 626-235-0591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC16462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: