Healthcare Provider Details

I. General information

NPI: 1508071069
Provider Name (Legal Business Name): MARY HUNTER ELLEGOOD L. AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 CALIFORNIA AVE
VENICE CA
90291-3442
US

IV. Provider business mailing address

722 CALIFORNIA AVE
VENICE CA
90291-3442
US

V. Phone/Fax

Practice location:
  • Phone: 310-613-8375
  • Fax:
Mailing address:
  • Phone: 310-613-8375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC7257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: