Provider Demographics
NPI:1477616480
Name:SON, MOO AH (LAC)
Entity Type:Individual
Prefix:
First Name:MOO
Middle Name:AH
Last Name:SON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3388 W 8TH ST
Mailing Address - Street 2:MITA ACUPUNTURE & HERBS CLINIC #205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-2882
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3388 W 8TH ST
Practice Address - Street 2:#205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-2882
Practice Address - Country:US
Practice Address - Phone:213-368-0073
Practice Address - Fax:213-368-0267
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAAC4191171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2799226Medicaid
CA2799226Medicaid