Provider Demographics
NPI:1124485289
Name:WELLNESS ACUPUNCTURE CLINIC
Entity type:Organization
Organization Name:WELLNESS ACUPUNCTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAE
Authorized Official - Middle Name:HUI
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OMD LAC
Authorized Official - Phone:213-905-0566
Mailing Address - Street 1:1866 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311
Mailing Address - Country:US
Mailing Address - Phone:213-905-0566
Mailing Address - Fax:
Practice Address - Street 1:1866 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311
Practice Address - Country:US
Practice Address - Phone:213-905-0566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15436251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management