Healthcare Provider Details

I. General information

NPI: 1780281188
Provider Name (Legal Business Name): MELISSA OLIVIA RODRIGUEZ L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E BROADWAY STE 203
GLENDALE CA
91205-2490
US

IV. Provider business mailing address

1526 E WILSON AVE
GLENDALE CA
91206-4035
US

V. Phone/Fax

Practice location:
  • Phone: 818-442-3368
  • Fax:
Mailing address:
  • Phone: 818-442-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: