Healthcare Provider Details

I. General information

NPI: 1659514974
Provider Name (Legal Business Name): SHAN MAO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 WILSHIRE BLVD SUITE 205
LOS ANGELES CA
90048
US

IV. Provider business mailing address

6360 WILSHIRE BLVD SUITE 205
LOS ANGELES CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 818-808-3518
  • Fax:
Mailing address:
  • Phone: 818-808-3518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC23-23
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: