Provider Demographics
NPI:1609080456
Name:IM, HWA CHAN (LAC)
Entity Type:Individual
Prefix:
First Name:HWA
Middle Name:CHAN
Last Name:IM
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 1:9722 EAST LAS TUNAS DRIVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780
Mailing Address - Country:US
Mailing Address - Phone:213-590-3943
Mailing Address - Fax:
Practice Address - Street 1:9722 EAST LAS TUNAS DRIVE
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780
Practice Address - Country:US
Practice Address - Phone:213-590-3943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9740171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5780836Medicaid