Healthcare Provider Details

I. General information

NPI: 1588428262
Provider Name (Legal Business Name): EXPANSE WELLNESS ACUPUNCTURE AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13906 FIJI WAY APT 352
MARINA DEL REY CA
90292-6934
US

IV. Provider business mailing address

13906 FIJI WAY APT 352
MARINA DEL REY CA
90292-6934
US

V. Phone/Fax

Practice location:
  • Phone: 818-373-9014
  • Fax:
Mailing address:
  • Phone: 818-373-9014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: WENDY CHAN
Title or Position: OWNER
Credential: DPT, LAC, DIPL OM
Phone: 818-373-9014