Provider Demographics
NPI:1194859504
Name:CHANG, SU-JUAN (CA)
Entity Type:Individual
Prefix:
First Name:SU-JUAN
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8341 9TH ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5037
Mailing Address - Country:US
Mailing Address - Phone:626-757-9909
Mailing Address - Fax:
Practice Address - Street 1:1121 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3610
Practice Address - Country:US
Practice Address - Phone:626-757-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5538171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0055380Medicaid