Provider Demographics
NPI:1538390075
Name:FOUNTAIN OF YOUTH INTERGRATIVE MEDICAL GROUP INC
Entity type:Organization
Organization Name:FOUNTAIN OF YOUTH INTERGRATIVE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LIN-HSING
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOU
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:626-683-8550
Mailing Address - Street 1:700 E WALNUT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1685
Mailing Address - Country:US
Mailing Address - Phone:626-683-8550
Mailing Address - Fax:626-683-8550
Practice Address - Street 1:700 E WALNUT ST STE 1
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1685
Practice Address - Country:US
Practice Address - Phone:626-683-8550
Practice Address - Fax:626-683-8550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13051171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty