Healthcare Provider Details

I. General information

NPI: 1245610195
Provider Name (Legal Business Name): SOURCE POINT WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3036 GLENDALE BLVD
LOS ANGELES CA
90039
US

IV. Provider business mailing address

3036 GLENDALE BLVD
LOS ANGELES CA
90039
US

V. Phone/Fax

Practice location:
  • Phone: 424-835-0884
  • Fax: 323-978-5158
Mailing address:
  • Phone: 424-835-0884
  • Fax: 323-978-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. AMANDA COHEN
Title or Position: DOCTOR, OWNER
Credential: DAOM, L.A.C
Phone: 424-835-0884