Healthcare Provider Details

I. General information

NPI: 1881801660
Provider Name (Legal Business Name): KOALA BEAR MOORE L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 STUART ST
BERKELEY CA
94705-1109
US

IV. Provider business mailing address

581 59TH ST
OAKLAND CA
94609-1570
US

V. Phone/Fax

Practice location:
  • Phone: 510-705-8755
  • Fax: 510-705-8520
Mailing address:
  • Phone: 510-393-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC11779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: