Provider Demographics
NPI:1679848196
Name:CHANG, KUO-CHUNG (LAC)
Entity Type:Individual
Prefix:
First Name:KUO-CHUNG
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MINEOLA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577
Mailing Address - Country:US
Mailing Address - Phone:516-626-8966
Mailing Address - Fax:516-626-8967
Practice Address - Street 1:59 MINEOLA AVE
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577
Practice Address - Country:US
Practice Address - Phone:516-626-8966
Practice Address - Fax:516-626-8967
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004634-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist