Provider Demographics
NPI:1154538965
Name:FANG, HUAN-WEN (LIC AC)
Entity type:Individual
Prefix:
First Name:HUAN-WEN
Middle Name:
Last Name:FANG
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MASS AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3739
Mailing Address - Country:US
Mailing Address - Phone:978-429-8369
Mailing Address - Fax:
Practice Address - Street 1:411 MASS AVE STE 304
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3739
Practice Address - Country:US
Practice Address - Phone:508-366-5773
Practice Address - Fax:508-366-6523
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1154538965OtherLAC