Healthcare Provider Details

I. General information

NPI: 1801217195
Provider Name (Legal Business Name): ELAINE TEOLOGO LVN, CMT, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 3RD AVE
OAKLAND CA
94606-1725
US

IV. Provider business mailing address

1638 3RD AVE
OAKLAND CA
94606-1725
US

V. Phone/Fax

Practice location:
  • Phone: 310-987-1453
  • Fax:
Mailing address:
  • Phone: 310-987-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18490
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: