Healthcare Provider Details

I. General information

NPI: 1770021255
Provider Name (Legal Business Name): KAN WA YEUNG LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6580 OLD MONROE RD STE A
INDIAN TRAIL NC
28079-5362
US

IV. Provider business mailing address

449 KINARD CT
MATTHEWS NC
28104-5003
US

V. Phone/Fax

Practice location:
  • Phone: 917-886-6225
  • Fax: 917-591-1525
Mailing address:
  • Phone: 917-886-6225
  • Fax: 917-591-1525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005916-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: