Healthcare Provider Details

I. General information

NPI: 1528149069
Provider Name (Legal Business Name): BRENDA BONILLA SMITH L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 S CHESTER AVE STE 101
PASADENA CA
91106-5805
US

IV. Provider business mailing address

99 S CHESTER AVE STE 101
PASADENA CA
91106-5805
US

V. Phone/Fax

Practice location:
  • Phone: 626-356-3220
  • Fax: 626-356-3222
Mailing address:
  • Phone: 626-356-3220
  • Fax: 626-356-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC7809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: