=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831663830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING ROOTS COMMUNITY ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2019
-----------------------------------------------------
Last Update Date | 01/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17541 IRVINE BLVD STE D
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-900-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17541 IRVINE BLVD STE D
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-900-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, LICENSED ACUPUNCTURIST
-----------------------------------------------------
Name | ALYSSA ANN HOUSER
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 657-900-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------