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General NPI Number Information
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NPI Number | 1316240336
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Entity Type | Individual
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Provider Name | KATHLEEN RUSSELL PORT L. AC.
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Gender | Female
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Dates
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Enumeration Date | 12/14/2010
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Last Update Date | 12/14/2010
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Provider Practice Location Address
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Address Line | 2211 CORINTH AVE SUITE 202
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City | LOS ANGELES
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State | CA
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Zip | 90064-1650
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Country | US
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Telephone | 310-230-0280
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Fax | 310-496-2108
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Provider Business Mailing Address
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Address Line | 657 EL MEDIO AVE
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City | PACIFIC PALISADES
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State | CA
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Zip | 90272-4226
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Country | US
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Telephone | 310-230-0280
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Fax | 310-496-2108
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC6282
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License Number State | CA
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