=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316314974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL ACUPUNCTURE & NATURAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2015
-----------------------------------------------------
Last Update Date | 08/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1831 ORANGE AVE STE E
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-646-4325
-----------------------------------------------------
Fax | 949-646-4313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1831 ORANGE AVE STE E
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-646-4325
-----------------------------------------------------
Fax | 949-646-4313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OWNER
-----------------------------------------------------
Name | TINA YANG
-----------------------------------------------------
Credential | MS, LAC
-----------------------------------------------------
Telephone | 949-646-4325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC9786
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC16641
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | ND82
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | ND228
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC8700
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------