MEDICARE: DIA VICKERY PHD(THEOLOGY), LICENSED ACUPUNCTURIST; A PROFESSIONAL CORP

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	AC 9644	CA

General Provider Information

NPI Number	:	1720449051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIA VICKERY PHD(THEOLOGY), LICENSED ACUPUNCTURIST; A PROFESSIONAL CORP

Provider Business Mailing Address
First Line	:	20750 VENTURA BLVD STE 203
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-6693
Country	:	US
Telephone Number	:	818-578-6730
Fax Number	:	818-578-6731

Provider Business Practice Location Address
First Line	:	20750 VENTURA BLVD STE 203
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-6693
Country	:	US
Telephone Number	:	818-578-6730
Fax Number	:	818-578-6731

Authorized Official
Title or Position	:	PRES/CEO
Name	:	DR. DIA VICKERY
Credential	:	PHD LAC
Telephone Number	:	818-578-6730

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	06/28/2023

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