=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568592657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED PAIN CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 10/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7151 LINCOLN AVE STE K
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90620-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-952-1080
-----------------------------------------------------
Fax | 714-952-1660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7151 LINCOLN AVE STE K
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90620-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-952-1080
-----------------------------------------------------
Fax | 714-952-1660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, PRESIDENT
-----------------------------------------------------
Name | DR. KHANH MINH LAM
-----------------------------------------------------
Credential | O.M.D., L.AC.
-----------------------------------------------------
Telephone | 714-952-1080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC3621
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A84750
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------