Provider Demographics
NPI:1437933207
Name:SU, TAO
Entity Type:Individual
Prefix:
First Name:TAO
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 MOUNTAIR AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-3624
Mailing Address - Country:US
Mailing Address - Phone:626-673-3990
Mailing Address - Fax:
Practice Address - Street 1:3460 OCEAN VIEW BLVD STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-3304
Practice Address - Country:US
Practice Address - Phone:818-957-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18099171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist