Provider Demographics
NPI:1043481104
Name:LU, TYEHAO M (LAC, MAOM)
Entity type:Individual
Prefix:
First Name:TYEHAO
Middle Name:M
Last Name:LU
Suffix:
Gender:M
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3836
Mailing Address - Country:US
Mailing Address - Phone:801-463-1101
Mailing Address - Fax:
Practice Address - Street 1:3220 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3836
Practice Address - Country:US
Practice Address - Phone:801-463-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6892381-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist