Provider Demographics
NPI:1033441902
Name:MOON, SAM LYEON (LAC)
Entity Type:Individual
Prefix:
First Name:SAM LYEON
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1220 UNIVERSITY DR
Mailing Address - Street 2:#202B
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4262
Mailing Address - Country:US
Mailing Address - Phone:408-930-7706
Mailing Address - Fax:
Practice Address - Street 1:1288 KIFER RD
Practice Address - Street 2:#202
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-5327
Practice Address - Country:US
Practice Address - Phone:408-720-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13171171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist