Healthcare Provider Details

I. General information

NPI: 1437779642
Provider Name (Legal Business Name): ORIGINAL BREATH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 N LA CIENEGA BLVD STE 203
WEST HOLLYWOOD CA
90069-2493
US

IV. Provider business mailing address

1106 N LA CIENEGA BLVD STE 206
WEST HOLLYWOOD CA
90069-2493
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-8500
  • Fax: 310-504-3171
Mailing address:
  • Phone: 310-980-9764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE BURTON
Title or Position: PHYSICIAN
Credential: DAOM
Phone: 310-980-9764