Provider Demographics
NPI:1558812180
Name:CHANG, CHRISTINE (LAC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:CHANG
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 1:105 ALTA LOMA DR APT 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3183
Mailing Address - Country:US
Mailing Address - Phone:858-361-8158
Mailing Address - Fax:
Practice Address - Street 1:1720 S AMPHLETT BLVD
Practice Address - Street 2:#168
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2702
Practice Address - Country:US
Practice Address - Phone:650-572-1628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND 788175F00000X
CAAC17051171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath