Provider Demographics
NPI:1780121657
Name:LIVING WELL MEDICAL CLINIC
Entity type:Organization
Organization Name:LIVING WELL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-979-7643
Mailing Address - Street 1:21102 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2022
Mailing Address - Country:US
Mailing Address - Phone:909-979-7643
Mailing Address - Fax:
Practice Address - Street 1:21102 NORTHVIEW DR
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2022
Practice Address - Country:US
Practice Address - Phone:909-979-7643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17127171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty