Healthcare Provider Details

I. General information

NPI: 1780145581
Provider Name (Legal Business Name): JONATHAN LAW L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 MESA VERDE DR E STE 111
COSTA MESA CA
92626-5221
US

IV. Provider business mailing address

1525 MESA VERDE DR E STE 111
COSTA MESA CA
92626-5221
US

V. Phone/Fax

Practice location:
  • Phone: 949-642-8883
  • Fax: 949-207-6333
Mailing address:
  • Phone: 949-642-8883
  • Fax: 949-207-6333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC4726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: