Healthcare Provider Details

I. General information

NPI: 1821184235
Provider Name (Legal Business Name): CRAIG JACE PA, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10843 MAGNOLIA BLVD
NORTH HOLLYWOOD CA
91601
US

IV. Provider business mailing address

10843 MAGNOLIA BLVD
NORTH HOLLYWOOD CA
91601
US

V. Phone/Fax

Practice location:
  • Phone: 818-505-8610
  • Fax:
Mailing address:
  • Phone: 818-505-8610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12998
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number3835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: