Basic Information
| Provider Information | |||||||||
| NPI: | 1003143645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYKSTRA | ||||||||
| FirstName: | YIQUN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LAC. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FU | ||||||||
| OtherFirstName: | YIQUN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | LAC. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 23232 PERALTA DR | ||||||||
| Address2: | STE 108 | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926531443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493340638 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23232 PERALTA DR | ||||||||
| Address2: | STE 108 | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926531443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493340638 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2009 | ||||||||
| LastUpdateDate: | 11/03/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC 13325 | CA | Y | Other Service Providers | Acupuncturist |
No ID Information.