Healthcare Provider Details

I. General information

NPI: 1891482519
Provider Name (Legal Business Name): MYODETOX CALIFORNIA PC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8354 SANTA MONICA BLVD
WEST HOLLYWOOD CA
90069-4313
US

IV. Provider business mailing address

8354 SANTA MONICA BLVD
WEST HOLLYWOOD CA
90069-4313
US

V. Phone/Fax

Practice location:
  • Phone: 323-831-2455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT MARCACCIO
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 917-327-0019