MEDICARE: KIYOHIDE TSUBAKIYAMA L.AC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC 3953	CA

General Provider Information

NPI Number	:	1609903863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIYOHIDE TSUBAKIYAMA L.AC

Provider Business Mailing Address
First Line	:	1227 LINCOLN BLVD # 303
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-1710
Country	:	US
Telephone Number	:	310-394-2340
Fax Number	:	310-394-3831

Provider Business Practice Location Address
First Line	:	1227 LINCOLN BLVD # 303
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-1710
Country	:	US
Telephone Number	:	310-394-2340
Fax Number	:	310-394-3831

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/08/2007

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