Healthcare Provider Details

I. General information

NPI: 1649500034
Provider Name (Legal Business Name): SHELLEY ALLISON SOVOLA L.AC.,OMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 NORTHCREST DR
CRESCENT CITY CA
95531-2322
US

IV. Provider business mailing address

PO BOX 6969
BROOKINGS OR
97415-0355
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-3000
  • Fax: 541-469-2180
Mailing address:
  • Phone: 541-469-3354
  • Fax: 541-469-2180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC1181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: