Provider Demographics
NPI:1649283961
Name:NGUYEN, SOPHIE THUY (LAC)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:THUY
Last Name:NGUYEN
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 1:5418 W CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-1807
Mailing Address - Country:US
Mailing Address - Phone:909-629-9090
Mailing Address - Fax:714-839-1141
Practice Address - Street 1:1148 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5827
Practice Address - Country:US
Practice Address - Phone:909-629-9090
Practice Address - Fax:714-839-1141
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9634171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0096340Medicaid
CAAC0096341Medicaid