Provider Demographics
NPI:1114475985
Name:FANG, BO (LAC)
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 OLD TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3450
Mailing Address - Country:US
Mailing Address - Phone:203-305-2141
Mailing Address - Fax:
Practice Address - Street 1:35 OLD TAVERN RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3450
Practice Address - Country:US
Practice Address - Phone:203-305-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000658171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist