Healthcare Provider Details

I. General information

NPI: 1316689839
Provider Name (Legal Business Name): MAMIE HUANG L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RACQUET CLUB RD
LELAND MS
38756-3100
US

IV. Provider business mailing address

1 RACQUET CLUB RD
LELAND MS
38756-3100
US

V. Phone/Fax

Practice location:
  • Phone: 979-575-6772
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00019
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: