Healthcare Provider Details

I. General information

NPI: 1760934236
Provider Name (Legal Business Name): WADE THOREN L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N ROBERTSON BLVD SUITE 301
BEVERLY HILLS CA
90211-1769
US

IV. Provider business mailing address

530 S HEWITT ST #234
LOS ANGELES CA
90013-2286
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-8256
  • Fax:
Mailing address:
  • Phone: 213-926-9264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 15445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: