Healthcare Provider Details

I. General information

NPI: 1326458076
Provider Name (Legal Business Name): BONITA MAKUCH L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2014
Last Update Date: 05/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 RIVERSIDE DR STE 8
STUDIO CITY CA
91602-1066
US

IV. Provider business mailing address

5101 MONTEZUMA ST
LOS ANGELES CA
90042-3230
US

V. Phone/Fax

Practice location:
  • Phone: 818-760-4808
  • Fax:
Mailing address:
  • Phone: 323-333-3258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberA16028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: