=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265975585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH M. DESTEFANO II, D.AC., L.AC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2016
-----------------------------------------------------
Last Update Date | 11/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8701 TRUXTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-853-0784
-----------------------------------------------------
Fax | 310-307-2989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8701 TRUXTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-853-0784
-----------------------------------------------------
Fax | 310-307-2989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH MICHAEL DE STEFANO II
-----------------------------------------------------
Credential | D.AC., L.AC.
-----------------------------------------------------
Telephone | 310-853-0784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | DA00454
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | CMT12010
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC16965
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------