Healthcare Provider Details

I. General information

NPI: 1336458611
Provider Name (Legal Business Name): RYAN FONG LA.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 E GREEN ST STE 106
PASADENA CA
91106-2413
US

IV. Provider business mailing address

1060 E GREEN ST STE 106
PASADENA CA
91106-2413
US

V. Phone/Fax

Practice location:
  • Phone: 323-423-3061
  • Fax:
Mailing address:
  • Phone: 323-423-3061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC13791
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: