Provider Demographics
NPI:1962720110
Name:WIDJAJA, IRWAN (LAC)
Entity type:Individual
Prefix:MR
First Name:IRWAN
Middle Name:
Last Name:WIDJAJA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 W LONGHILL DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4518
Mailing Address - Country:US
Mailing Address - Phone:626-888-9119
Mailing Address - Fax:
Practice Address - Street 1:1481 W LONGHILL DR
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4518
Practice Address - Country:US
Practice Address - Phone:626-888-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2013-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13474171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist