Healthcare Provider Details

I. General information

NPI: 1154874071
Provider Name (Legal Business Name): DUCK SOO YOO LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 VINELAND AVE UNIT 216
SUN VALLEY CA
91352-5088
US

IV. Provider business mailing address

446 RIVERDALE DR APT 4
GLENDALE CA
91204-1555
US

V. Phone/Fax

Practice location:
  • Phone: 213-219-0763
  • Fax:
Mailing address:
  • Phone: 213-219-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 9904
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: