Healthcare Provider Details

I. General information

NPI: 1457576290
Provider Name (Legal Business Name): SCOTT MICHAEL EIDE L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 GOLDEN SHR SUITE 220
LONG BEACH CA
90802-4214
US

IV. Provider business mailing address

2275 CLARK AVE
LONG BEACH CA
90815-2523
US

V. Phone/Fax

Practice location:
  • Phone: 562-495-5898
  • Fax: 562-983-5454
Mailing address:
  • Phone: 562-822-7639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 11147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: