Healthcare Provider Details

I. General information

NPI: 1902498157
Provider Name (Legal Business Name): MASON LAI LE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHARLOTTE AURORA LAI LE

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 E GREEN ST STE 207
PASADENA CA
91106-2417
US

IV. Provider business mailing address

41 S CHESTER AVE STE A1
PASADENA CA
91106-3104
US

V. Phone/Fax

Practice location:
  • Phone: 626-460-0048
  • Fax:
Mailing address:
  • Phone: 626-460-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License NumberL9669
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL9669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: