Provider Demographics
NPI:1740416742
Name:REN, BO (LAC)
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:REN
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 1:1205 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1954
Mailing Address - Country:US
Mailing Address - Phone:714-391-2727
Mailing Address - Fax:
Practice Address - Street 1:1205 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1954
Practice Address - Country:US
Practice Address - Phone:714-391-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12928171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist