Provider Demographics
NPI:1003242728
Name:NGUYEN, MAN CONG (LAC)
Entity Type:Individual
Prefix:
First Name:MAN
Middle Name:CONG
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7995 PRINCEVALLE ST STE 130
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5042
Mailing Address - Country:US
Mailing Address - Phone:408-854-0109
Mailing Address - Fax:
Practice Address - Street 1:2663 CROPLEY AVE STE 20
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-3707
Practice Address - Country:US
Practice Address - Phone:408-854-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15178171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist