Healthcare Provider Details

I. General information

NPI: 1760298913
Provider Name (Legal Business Name): PUN CHANG LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 HIGHWAY 169 N STE 103
NEW HOPE MN
55428-4032
US

IV. Provider business mailing address

4900 HIGHWAY 169 N STE 103
NEW HOPE MN
55428-4032
US

V. Phone/Fax

Practice location:
  • Phone: 651-434-5879
  • Fax:
Mailing address:
  • Phone: 651-434-5879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2072
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: