Healthcare Provider Details

I. General information

NPI: 1780003350
Provider Name (Legal Business Name): AMANDA COHEN DAOM, L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
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 NumberCA15953
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberCA15953
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCA15953
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberCA15953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: