MEDICARE: SHOU-YUAN FAN L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	25MZ00073400	NJ
2	171100000X	Acupuncturist	004232	NY

General Provider Information

NPI Number	:	1003134206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHOU-YUAN FAN L.AC.

Provider Business Mailing Address
First Line	:	500 MOUNT PROSPECT AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07104-2904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 MOUNT PROSPECT AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07104-2904
Country	:	US
Telephone Number	:	973-350-0073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2010
Last Update Date	:	03/29/2012

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