Provider Demographics
NPI:1053325829
Name:SU, HUACHANG (LAC)
Entity Type:Individual
Prefix:
First Name:HUACHANG
Middle Name:
Last Name:SU
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 1:925 S ATLANTIC BLVD
Mailing Address - Street 2:SUITE 206B
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1063
Mailing Address - Country:US
Mailing Address - Phone:626-300-8687
Mailing Address - Fax:
Practice Address - Street 1:925 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 206B
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1063
Practice Address - Country:US
Practice Address - Phone:626-300-8687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7183171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC7183OtherSTATE LICENSE
CAAC0071830Medicaid