Healthcare Provider Details

I. General information

NPI: 1649643784
Provider Name (Legal Business Name): LIFE HERBS ACUPUNCTURE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W REDONDO BEACH BLVD STE 111
GARDENA CA
90248-1612
US

IV. Provider business mailing address

555 W REDONDO BEACH BLVD STE 111
GARDENA CA
90248-1612
US

V. Phone/Fax

Practice location:
  • Phone: 310-756-0001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberAC8057
License Number StateCA

VIII. Authorized Official

Name: DR. DONG PARK
Title or Position: ACUPUNCTURIST
Credential:
Phone: 213-700-9314