Healthcare Provider Details

I. General information

NPI: 1548502099
Provider Name (Legal Business Name): SONJUE CHUNGKOLTSOV L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 HAMILTON AVE
SAN JOSE CA
95125-5624
US

IV. Provider business mailing address

390 LA STRADA DR # 12
SAN JOSE CA
95123-1018
US

V. Phone/Fax

Practice location:
  • Phone: 408-896-6355
  • Fax:
Mailing address:
  • Phone: 408-896-6355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC15025
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: