=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407349913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NDAYAPA PUSSADHAMMA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2018
-----------------------------------------------------
Last Update Date | 06/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1253 VINE ST STE 10
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90038-1662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-747-0987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13079 FRANCISQUITO AVE
-----------------------------------------------------
City | BALDWIN PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91706-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-549-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC18001
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------