Healthcare Provider Details

I. General information

NPI: 1598055980
Provider Name (Legal Business Name): CANDACE D VEACH MTOM, L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 SAN VICENTE BLVD SUITE 605
LOS ANGELES CA
90049-5106
US

IV. Provider business mailing address

11611 SAN VICENTE BLVD. SUITE 605
LOS ANGELES CA
90049
US

V. Phone/Fax

Practice location:
  • Phone: 310-795-8500
  • Fax: 310-826-9152
Mailing address:
  • Phone: 310-795-8500
  • Fax: 310-826-9152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberAC#8307
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC#8307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: