Healthcare Provider Details

I. General information

NPI: 1912355181
Provider Name (Legal Business Name): FULLER ACUPUNCTURE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2016
Last Update Date: 05/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S FAIR OAKS AVE STE 205
PASADENA CA
91105-1945
US

IV. Provider business mailing address

1 S FAIR OAKS AVE STE 205
PASADENA CA
91105-1945
US

V. Phone/Fax

Practice location:
  • Phone: 626-318-9174
  • Fax: 626-356-1888
Mailing address:
  • Phone: 626-318-9174
  • Fax: 626-356-1888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number8215
License Number StateCA

VIII. Authorized Official

Name: MS. FEI HE
Title or Position: OWNER
Credential: LA.C
Phone: 626-318-9174