MEDICARE: BLAKE JOHNATHAN BROUKHIM LAC

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	AC20441	CA

General Provider Information

NPI Number	:	1427921378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE JOHNATHAN BROUKHIM LAC

Provider Business Mailing Address
First Line	:	10614 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2373
Country	:	US
Telephone Number	:	818-755-6070
Fax Number	:	818-755-1870

Provider Business Practice Location Address
First Line	:	10614 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2373
Country	:	US
Telephone Number	:	818-755-6070
Fax Number	:	818-755-1870

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

Provider Enumeration Date	:	09/26/2025
Last Update Date	:	10/27/2025

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