Healthcare Provider Details

I. General information

NPI: 1275837841
Provider Name (Legal Business Name): GREEN HEALTH ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W 6TH ST
SAN PEDRO CA
90731-3300
US

IV. Provider business mailing address

150 W 6TH ST
SAN PEDRO CA
90731-3300
US

V. Phone/Fax

Practice location:
  • Phone: 310-831-2202
  • Fax:
Mailing address:
  • Phone: 310-831-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC10112
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2431
License Number StateCA

VIII. Authorized Official

Name: OLESIA FARBEROV
Title or Position: LICENSED ACUPUNCTURIST & HERBALIST
Credential: L.AC.
Phone: 310-831-2202