MEDICARE: JOSEPH M. DESTEFANO II, D.AC., 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	DA00454	RI
2	225700000X	Massage Therapist	CMT12010	CA
3	171100000X	Acupuncturist	AC16965	CA

General Provider Information

NPI Number	:	1265975585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSEPH M. DESTEFANO II, D.AC., L.AC.

Provider Business Mailing Address
First Line	:	8701 TRUXTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3911
Country	:	US
Telephone Number	:	310-853-0784
Fax Number	:	310-307-2989

Provider Business Practice Location Address
First Line	:	8701 TRUXTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3911
Country	:	US
Telephone Number	:	310-853-0784
Fax Number	:	310-307-2989

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSEPH MICHAEL DE STEFANO II
Credential	:	D.AC., L.AC.
Telephone Number	:	310-853-0784

Provider Enumeration Date	:	11/18/2016
Last Update Date	:	11/18/2016

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