Provider Demographics
NPI:1801230156
Name:SU, KUAN-REN (LAC, MSTOM)
Entity Type:Individual
Prefix:
First Name:KUAN-REN
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 CHICAGO AVE
Mailing Address - Street 2:UNIT 401
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-6509
Mailing Address - Country:US
Mailing Address - Phone:847-508-1833
Mailing Address - Fax:
Practice Address - Street 1:1236 CHICAGO AVE
Practice Address - Street 2:UNIT 401
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-6509
Practice Address - Country:US
Practice Address - Phone:847-508-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001124171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist