MEDICARE: SPORTS PERFORMANCE ACUPUNCTURE

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	16474	CA

General Provider Information

NPI Number	:	1528517190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS PERFORMANCE ACUPUNCTURE

Provider Business Mailing Address
First Line	:	1269 LINDELL DR
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94596-6040
Country	:	US
Telephone Number	:	925-785-7364
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 OAK RD STE 120
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94597-2039
Country	:	US
Telephone Number	:	925-785-7364
Fax Number	:

Authorized Official
Title or Position	:	ACUPUNCTURIST
Name	:	JOSH TAVES
Credential	:	LAC
Telephone Number	:	925-785-7364

Provider Enumeration Date	:	09/23/2016
Last Update Date	:	09/23/2016

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