Healthcare Provider Details

I. General information

NPI: 1780803130
Provider Name (Legal Business Name): SANG YOON LAC OMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15243 VANOWEN ST STE 400
VAN NUYS CA
91405-3654
US

IV. Provider business mailing address

15243 VANOWEN ST STE 400
VAN NUYS CA
91405-3654
US

V. Phone/Fax

Practice location:
  • Phone: 213-675-7662
  • Fax: 818-994-7687
Mailing address:
  • Phone: 213-675-7662
  • Fax: 818-994-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC9103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: