Healthcare Provider Details

I. General information

NPI: 1316349335
Provider Name (Legal Business Name): MICHAEL MOY LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7320 S MADISON ST STE 900
WILLOWBROOK IL
60527-3608
US

IV. Provider business mailing address

7320 S MADISON ST STE 900
WILLOWBROOK IL
60527-3608
US

V. Phone/Fax

Practice location:
  • Phone: 630-455-1528
  • Fax:
Mailing address:
  • Phone: 630-455-1528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198-000243
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: