Healthcare Provider Details

I. General information

NPI: 1710409131
Provider Name (Legal Business Name): LISA WEBER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER STE 250
GLENDALE CA
91206-4075
US

IV. Provider business mailing address

2355 WESTWOOD BLVD # 652
LOS ANGELES CA
90064-2109
US

V. Phone/Fax

Practice location:
  • Phone: 949-836-2305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: