Healthcare Provider Details

I. General information

NPI: 1053450189
Provider Name (Legal Business Name): LOS ANGELES CENTER FOR INTEGRATED MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 N CAMDEN DR
BEVERLY HILLS CA
90210-4507
US

IV. Provider business mailing address

468 N CAMDEN DR
BEVERLY HILLS CA
90210-4507
US

V. Phone/Fax

Practice location:
  • Phone: 310-497-1774
  • Fax:
Mailing address:
  • Phone: 310-497-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberPENDING GRADUATION
License Number StateCA

VIII. Authorized Official

Name: DR. MARK WAYNE BERRY
Title or Position: DIRECTOR OF MEDICINE
Credential: PENDING GRADUATION
Phone: 310-497-1774