Healthcare Provider Details

I. General information

NPI: 1235526005
Provider Name (Legal Business Name): ELLEN GEHEBER DAVIS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11965 VENICE BLVD SUITE 407
LOS ANGELES CA
90066-3979
US

IV. Provider business mailing address

8346 MANITOBA ST APT 3
PLAYA DEL REY CA
90293-8217
US

V. Phone/Fax

Practice location:
  • Phone: 424-625-4228
  • Fax:
Mailing address:
  • Phone: 310-490-3067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number16531
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: