Healthcare Provider Details

I. General information

NPI: 1639550247
Provider Name (Legal Business Name): HOLISTIC SPORTS ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E DOMINGUEZ ST SUITE 101
CARSON CA
90746-3600
US

IV. Provider business mailing address

1627 N POINSETTIA PL APT.17
LOS ANGELES CA
90046-3566
US

V. Phone/Fax

Practice location:
  • Phone: 310-327-1325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 14368
License Number StateCA

VIII. Authorized Official

Name: MELANI LEONARD-COOPER
Title or Position: OWNER/ACUPUNCTURIST
Credential: L.AC.
Phone: 323-710-6751