=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598137101
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEC BRIDGES LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2015
-----------------------------------------------------
Last Update Date | 06/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 COPELAND CT APT C
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90405-4478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-717-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 655 COPELAND CT APT C
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90405-4478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-717-5433
-----------------------------------------------------
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 | 16792
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------