Healthcare Provider Details

I. General information

NPI: 1780121657
Provider Name (Legal Business Name): LIVING WELL MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21102 NORTHVIEW DR
WALNUT CA
91789-2022
US

IV. Provider business mailing address

21102 NORTHVIEW DR
WALNUT CA
91789-2022
US

V. Phone/Fax

Practice location:
  • Phone: 909-979-7643
  • Fax:
Mailing address:
  • Phone: 909-979-7643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC17127
License Number StateCA

VIII. Authorized Official

Name: TRINA CHANG
Title or Position: OWNER
Credential:
Phone: 909-979-7643