Healthcare Provider Details

I. General information

NPI: 1467963884
Provider Name (Legal Business Name): JONATHAN NOBLEZA L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 TELEGRAPH AVE
BERKELEY CA
94705-1131
US

IV. Provider business mailing address

680 SPRUCE ST
BERKELEY CA
94707-1730
US

V. Phone/Fax

Practice location:
  • Phone: 510-863-1356
  • Fax:
Mailing address:
  • Phone: 510-863-1356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: