Provider Demographics
NPI:1477875862
Name:FANG MAO MEDICAL GROUP
Entity Type:Organization
Organization Name:FANG MAO MEDICAL GROUP
Other - Org Name:PROFOUND YOUTH ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHI FANG
Authorized Official - Middle Name:
Authorized Official - Last Name:HSU
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, OMD
Authorized Official - Phone:951-582-0999
Mailing Address - Street 1:760 WASHBURN AVE
Mailing Address - Street 2:SUITE # 23
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3303
Mailing Address - Country:US
Mailing Address - Phone:951-582-0999
Mailing Address - Fax:951-582-0900
Practice Address - Street 1:760 WASHBURN AVE
Practice Address - Street 2:SUITE # 23
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3303
Practice Address - Country:US
Practice Address - Phone:951-582-0999
Practice Address - Fax:951-582-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11187171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty