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General NPI Number Information
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NPI Number | 1619357415
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Entity Type | Organization
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Legal Business Name | ELYSIA LIFE CARE
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Dates
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Enumeration Date | 06/05/2015
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Last Update Date | 06/05/2015
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Provider Practice Location Address
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Address Line | 1821 WILSHIRE BLVD STE 500
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City | SANTA MONICA
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State | CA
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Zip | 90403-5679
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Country | US
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Telephone | 424-744-8366
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Fax |
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Provider Business Mailing Address
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Address Line | 1821 WILSHIRE BLVD STE 500
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City | SANTA MONICA
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State | CA
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Zip | 90403-5679
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | COO
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Name | DR. CARLA VIDOR
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Credential | L.AC DAOM
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Telephone | 310-924-5205
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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 | AC13025
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License Number State | CA
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