Healthcare Provider Details

I. General information

NPI: 1841605490
Provider Name (Legal Business Name): EMILY SMITH LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MILLER AVE
MILL VALLEY CA
94941-2817
US

IV. Provider business mailing address

54 SAN PABLO AVE
SAN RAFAEL CA
94903-4106
US

V. Phone/Fax

Practice location:
  • Phone: 415-757-7441
  • Fax:
Mailing address:
  • Phone: 415-757-7441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number4740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: