=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356854111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMALIA GARDNER, L.AC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2017
-----------------------------------------------------
Last Update Date | 11/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5028 EAGLE ROCK BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90041-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-579-9599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5028 EAGLE ROCK BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90041-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-579-9599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ACUPUNCTURIST
-----------------------------------------------------
Name | MRS. AMALIA TASOULA GARDNER
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 760-579-9599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC16632
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------