Healthcare Provider Details

I. General information

NPI: 1255811972
Provider Name (Legal Business Name): LONG VUONG LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 BALBOA AVE
SAN DIEGO CA
92117-5504
US

IV. Provider business mailing address

5005 TISELLE WAY
SAN DIEGO CA
92105-5322
US

V. Phone/Fax

Practice location:
  • Phone: 858-272-4627
  • Fax:
Mailing address:
  • Phone: 619-788-7632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC17785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: