Provider Demographics
NPI:1922561323
Name:YUNG, KELLY PEICHU (LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:PEICHU
Last Name:YUNG
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 1:11301 W OLYMPIC BLVD STE 425
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1653
Mailing Address - Country:US
Mailing Address - Phone:310-733-8086
Mailing Address - Fax:
Practice Address - Street 1:17203 VENTURA BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4054
Practice Address - Country:US
Practice Address - Phone:310-733-8086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18394171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist