Healthcare Provider Details

I. General information

NPI: 1164040432
Provider Name (Legal Business Name): ADDISON JAY TAYLOR L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E GREEN ST STE 310
PASADENA CA
91106-2401
US

IV. Provider business mailing address

1829 BARA RD
GLENDALE CA
91208-2501
US

V. Phone/Fax

Practice location:
  • Phone: 213-373-4778
  • Fax:
Mailing address:
  • Phone: 213-373-4778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18577
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: