Healthcare Provider Details

I. General information

NPI: 1831365139
Provider Name (Legal Business Name): ACU-ORTHOPEDICS & METABOLIC CLINIC, MATRIX MEDI-SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SANTA FE DR
ENCINITAS CA
92024-5132
US

IV. Provider business mailing address

345 SANTA FE DR
ENCINITAS CA
92024-5132
US

V. Phone/Fax

Practice location:
  • Phone: 760-207-1264
  • Fax:
Mailing address:
  • Phone: 760-207-1264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License NumberAC8992
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberAC8992
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAC8992
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberAC8992
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC8992
License Number StateCA

VIII. Authorized Official

Name: TASSY HENNESSY
Title or Position: OWNER
Credential: MSTOM, AAPOM, L.AC.
Phone: 760-207-1264