MEDICARE: MS. CARMEN LETICIA REYES 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	CA6619	CA

General Provider Information

NPI Number	:	1619015203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARMEN LETICIA REYES L.AC

Provider Business Mailing Address
First Line	:	4171 DIVISION ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-4205
Country	:	US
Telephone Number	:	323-257-5795
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 COLORADO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1338
Country	:	US
Telephone Number	:	323-255-6060
Fax Number	:

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

Provider Enumeration Date	:	02/03/2007
Last Update Date	:	07/08/2007

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