MEDICARE: ROXANA G. GRAVELLE 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	15150	CA

General Provider Information

NPI Number	:	1265860340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROXANA G. GRAVELLE L. AC.

Provider Business Mailing Address
First Line	:	4742 HALBRENT AVE
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-2420
Country	:	US
Telephone Number	:	310-909-4779
Fax Number	:

Provider Business Practice Location Address
First Line	:	12568 W WASHINGTON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5521
Country	:	US
Telephone Number	:	424-888-0339
Fax Number	:

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

Provider Enumeration Date	:	10/28/2013
Last Update Date	:	10/28/2013

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