Healthcare Provider Details

I. General information

NPI: 1033556899
Provider Name (Legal Business Name): MANDALA ACUPUNCTURE PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 LA VETA AVE
ENCINITAS CA
92024-2014
US

IV. Provider business mailing address

239 CONEFLOWER ST
ENCINITAS CA
92024-3302
US

V. Phone/Fax

Practice location:
  • Phone: 760-704-7712
  • Fax:
Mailing address:
  • Phone: 760-704-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 10913
License Number StateCA

VIII. Authorized Official

Name: ANDREA WERNER MILIOTIS
Title or Position: LICENSED ACUPUNCTURIST
Credential: L.AC.
Phone: 760-704-7712