Provider Demographics
NPI:1104029800
Name:XU, CHARLENE (LAC)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:XU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13103 40TH RD APT 10Y
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5214
Mailing Address - Country:US
Mailing Address - Phone:646-894-8963
Mailing Address - Fax:212-668-8283
Practice Address - Street 1:1201 NOSTRAND AVE STE BSMT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5911
Practice Address - Country:US
Practice Address - Phone:929-341-9586
Practice Address - Fax:619-268-6057
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002844-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLICENSEOther002844-1