Provider Demographics
NPI:1194105650
Name:TYSON, MIRA CHOI (LAC)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:CHOI
Last Name:TYSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MI
Other - Middle Name:RA
Other - Last Name:TYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1840 MACKENZIE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:UPPER ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2980
Mailing Address - Country:US
Mailing Address - Phone:614-500-3088
Mailing Address - Fax:614-305-6040
Practice Address - Street 1:1840 MACKENZIE DR STE 101
Practice Address - Street 2:
Practice Address - City:UPPER ARLINGTON
Practice Address - State:OH
Practice Address - Zip Code:43220-2980
Practice Address - Country:US
Practice Address - Phone:614-500-3088
Practice Address - Fax:614-305-6040
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000303171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0253510Medicaid