MEDICARE: ETI A CHALL 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	AC7996	CA

General Provider Information

NPI Number	:	1356587075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETI A CHALL L.AC.

Provider Business Mailing Address
First Line	:	4054 CENTRE ST APT 1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2634
Country	:	US
Telephone Number	:	866-968-4325
Fax Number	:	866-968-4325

Provider Business Practice Location Address
First Line	:	4054 CENTRE ST APT 1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2634
Country	:	US
Telephone Number	:	866-968-4325
Fax Number	:

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

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	11/26/2019

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Directions to “ ETI A CHALL L.AC.” Practice Location

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