Healthcare Provider Details

I. General information

NPI: 1760298137
Provider Name (Legal Business Name): CARLY IWASA LAC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 S EUCLID AVE
PASADENA CA
91101-3125
US

IV. Provider business mailing address

3980 WILSHIRE BLVD APT 401
LOS ANGELES CA
90010-4217
US

V. Phone/Fax

Practice location:
  • Phone: 208-739-3079
  • Fax:
Mailing address:
  • Phone: 208-739-3079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number20211
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: