Healthcare Provider Details

I. General information

NPI: 1578732210
Provider Name (Legal Business Name): KLAVA COUSINS L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 HOLLOW CORNER RD # 260
CULVER CITY CA
90230
US

IV. Provider business mailing address

PO BOX 661366
LOS ANGELES CA
90066
US

V. Phone/Fax

Practice location:
  • Phone: 310-348-0500
  • Fax: 310-348-0201
Mailing address:
  • Phone: 310-348-0500
  • Fax: 310-348-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberAC5626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: