Provider Demographics
NPI:1780064238
Name:IM, YANG TAEK (LAC)
Entity type:Individual
Prefix:
First Name:YANG TAEK
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:798 3/4 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2855
Mailing Address - Country:US
Mailing Address - Phone:213-800-4720
Mailing Address - Fax:
Practice Address - Street 1:2705 W 8TH ST STE B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1286
Practice Address - Country:US
Practice Address - Phone:213-800-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-31
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALA.C 13284171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist