Healthcare Provider Details

I. General information

NPI: 1912544099
Provider Name (Legal Business Name): JEEMENG LAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2019
Last Update Date: 12/07/2019
Certification Date: 12/07/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31836 ALVARADO BLVD
UNION CITY CA
94587-3913
US

IV. Provider business mailing address

1061 24TH ST
OAKLAND CA
94607-2948
US

V. Phone/Fax

Practice location:
  • Phone: 510-489-3955
  • Fax:
Mailing address:
  • Phone: 510-269-7739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number81171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: