MEDICARE: KENJI MATSUSAKA L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	17442	CA

General Provider Information

NPI Number	:	1003371121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENJI MATSUSAKA L.AC.

Provider Business Mailing Address
First Line	:	1307 24TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-2013
Country	:	US
Telephone Number	:	781-727-6341
Fax Number	:

Provider Business Practice Location Address
First Line	:	4847 NEWPORT AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3110
Country	:	US
Telephone Number	:	619-550-9747
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2019
Last Update Date	:	02/02/2019

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