Healthcare Provider Details

I. General information

NPI: 1275682106
Provider Name (Legal Business Name): IRIS GOLD OMD,L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 CAMINO ALTO
MILL VALLEY CA
94941-2254
US

IV. Provider business mailing address

131 CAMINO ALTO
MILL VALLEY CA
94941-2254
US

V. Phone/Fax

Practice location:
  • Phone: 415-381-3888
  • Fax: 415-381-9366
Mailing address:
  • Phone: 415-381-3888
  • Fax: 415-381-9366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC1498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: