MEDICARE: SAN DIEGO SPORTS ACUPUNCTURE, 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	14401	CA

General Provider Information

NPI Number	:	1508399569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIEGO SPORTS ACUPUNCTURE, INC

Provider Business Mailing Address
First Line	:	5465 MOREHOUSE DR
Second Line	:	100
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-4700
Country	:	US
Telephone Number	:	858-255-8070
Fax Number	:	858-750-2428

Provider Business Practice Location Address
First Line	:	5465 MOREHOUSE DR
Second Line	:	100
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-4700
Country	:	US
Telephone Number	:	858-255-8070
Fax Number	:	858-750-2428

Authorized Official
Title or Position	:	OWNER
Name	:	SEAN DAVIS
Credential	:	L.AC
Telephone Number	:	858-255-8070

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	04/06/2017

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