Healthcare Provider Details

I. General information

NPI: 1861272510
Provider Name (Legal Business Name): JACQUELINE MEDEIROS L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAC MEDEIROS L.AC

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 SAWTELLE BLVD
LOS ANGELES CA
90066-1408
US

IV. Provider business mailing address

161 OCEAN PARK BLVD APT C
SANTA MONICA CA
90405-3527
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-9018
  • Fax:
Mailing address:
  • Phone: 760-780-2697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC19841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: