Provider Demographics
NPI:1922278829
Name:LAKEFRONT ACUPUNCTURE CLINIC, LLC
Entity Type:Organization
Organization Name:LAKEFRONT ACUPUNCTURE CLINIC, LLC
Other - Org Name:LAKEFRONT ACUPUNCTURE AND CHINESE MEDICINE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:XIANHUI
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:952-200-1246
Mailing Address - Street 1:1644 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4595
Mailing Address - Country:US
Mailing Address - Phone:952-200-1246
Mailing Address - Fax:
Practice Address - Street 1:1644 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-4595
Practice Address - Country:US
Practice Address - Phone:952-200-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1270225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty