=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952059313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID VANG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2022
-----------------------------------------------------
Last Update Date | 03/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W 35TH ST STE 5B520
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60609-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-557-6304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18W243 STANDISH LN
-----------------------------------------------------
City | VILLA PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60181-3649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-960-4097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 198.01583
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------