Healthcare Provider Details

I. General information

NPI: 1861908550
Provider Name (Legal Business Name): TAYLOR MADE ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 UNIVERSITY AVE STE 207G
SAN DIEGO CA
92103-7308
US

IV. Provider business mailing address

1090 UNIVERSITY AVE STE 207G
SAN DIEGO CA
92103-7308
US

V. Phone/Fax

Practice location:
  • Phone: 619-458-9626
  • Fax: 619-228-9061
Mailing address:
  • Phone: 619-458-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC15111
License Number StateCA

VIII. Authorized Official

Name: TAYLOR TAYLOR
Title or Position: OWNER
Credential: LAC.
Phone: 619-458-9626