Healthcare Provider Details

I. General information

NPI: 1598938631
Provider Name (Legal Business Name): LISA HOLLINGSWORTH UPSHAW D.C., L. AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 VENICE BLVD
VENICE CA
90291-4801
US

IV. Provider business mailing address

318 LINCOLN BLVD STE 225
VENICE CA
90291-2827
US

V. Phone/Fax

Practice location:
  • Phone: 877-767-6217
  • Fax: 877-767-6217
Mailing address:
  • Phone: 310-396-3635
  • Fax: 877-767-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number29832
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC11018
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: