Provider Demographics
NPI:1578086062
Name:GRACE, SOPHIE W (ACUPUNCTURIST)
Entity Type:Individual
Prefix:MS
First Name:SOPHIE
Middle Name:W
Last Name:GRACE
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:MS
Other - First Name:HONGMEI
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:711 LA SERNA AVE
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-2748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:416 W LAS TUNAS DR STE 205
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1236
Practice Address - Country:US
Practice Address - Phone:626-264-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10089171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty