Provider Demographics
NPI:1518325158
Name:VONG, MARLENE AI VAN (LAC)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:AI VAN
Last Name:VONG
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 1:6191 CORNERSTONE CT E STE 113
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4739
Mailing Address - Country:US
Mailing Address - Phone:858-247-1787
Mailing Address - Fax:858-550-0153
Practice Address - Street 1:6191 CORNERSTONE CT E STE 113
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4739
Practice Address - Country:US
Practice Address - Phone:858-247-1787
Practice Address - Fax:858-550-0153
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 16771171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist