Healthcare Provider Details

I. General information

NPI: 1780141317
Provider Name (Legal Business Name): ITZEL CORONADO LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21040 HOMESTEAD RD STE 102
CUPERTINO CA
95014-0238
US

IV. Provider business mailing address

1534 LOCHNER DR
SAN JOSE CA
95127-4765
US

V. Phone/Fax

Practice location:
  • Phone: 408-413-8315
  • Fax: 408-743-5445
Mailing address:
  • Phone: 408-413-8315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: