MEDICARE: ANGEL GRACE HEALING CLINIC INC.

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

General Provider Information

NPI Number	:	1215495528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL GRACE HEALING CLINIC INC.

Provider Business Mailing Address
First Line	:	5757 W CENTURY BLVD STE 558
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-6454
Country	:	US
Telephone Number	:	213-268-7636
Fax Number	:

Provider Business Practice Location Address
First Line	:	5757 W CENTURY BLVD STE 558
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-6454
Country	:	US
Telephone Number	:	213-268-7636
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GRACE CHOI
Credential	:
Telephone Number	:	213-268-7636

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	03/05/2019

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