Healthcare Provider Details

I. General information

NPI: 1164592002
Provider Name (Legal Business Name): CHAU BAO NGUYEN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MOUNTAIN VIEW DRIVE
TUSTIN CA
92780
US

IV. Provider business mailing address

125 MOUNTAIN VIEW DRIVE
TUSTIN CA
92780
US

V. Phone/Fax

Practice location:
  • Phone: 714-573-9788
  • Fax: 714-573-9788
Mailing address:
  • Phone: 714-573-9788
  • Fax: 714-573-9788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC5557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: