Healthcare Provider Details

I. General information

NPI: 1255263943
Provider Name (Legal Business Name): SPROUT WELLNESS ACUPUNCTURE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 S PLYMOUTH BLVD
LOS ANGELES CA
90019-6898
US

IV. Provider business mailing address

1074 S PLYMOUTH BLVD
LOS ANGELES CA
90019-6898
US

V. Phone/Fax

Practice location:
  • Phone: 213-302-2477
  • Fax:
Mailing address:
  • Phone: 213-302-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: ANNICE PARK
Title or Position: CEO
Credential: ACUPUNCTURIST
Phone: 213-302-2477