Healthcare Provider Details

I. General information

NPI: 1245605690
Provider Name (Legal Business Name): PERSOMA WELLNESS - A PROFESSIONAL ACUPUNCTURE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SILVER SPUR RD # 112
ROLLING HILLS ESTATES CA
90274-3633
US

IV. Provider business mailing address

777 SILVER SPUR RD # 112
ROLLING HILLS ESTATES CA
90274-3633
US

V. Phone/Fax

Practice location:
  • Phone: 310-570-9723
  • Fax:
Mailing address:
  • Phone: 310-570-9723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC12304
License Number StateCA

VIII. Authorized Official

Name: MS. CHRISTINA M LODEN
Title or Position: PRESIDENT
Credential: L.AC.
Phone: 310-570-9723