Healthcare Provider Details

I. General information

NPI: 1205427242
Provider Name (Legal Business Name): IDYLLWILD COMMUNITY ACUPUNCTURE & BODYWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54445 N CIRCLE DRIVE, SUITE A
IDYLLWILD CA
92549
US

IV. Provider business mailing address

PO BOX 2421
IDYLLWILD CA
92549-2421
US

V. Phone/Fax

Practice location:
  • Phone: 859-396-0469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JULIE LIVELY
Title or Position: MANAGER
Credential: OT
Phone: 859-396-0469