Healthcare Provider Details

I. General information

NPI: 1982239687
Provider Name (Legal Business Name): ALYSSA TENNENBAUM GONG RD, LAC, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2634 PIEDMONT AVE
BERKELEY CA
94704-3413
US

IV. Provider business mailing address

2634 PIEDMONT AVE
BERKELEY CA
94704-3413
US

V. Phone/Fax

Practice location:
  • Phone: 310-749-1888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17272
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number636958
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: