MEDICARE: CARLA VIDOR 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	13025	CA

General Provider Information

NPI Number	:	1740518828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA VIDOR L.AC

Provider Business Mailing Address
First Line	:	644 TROPHY TRL
Second Line	:
City	:	TOPANGA
State	:	CA
Zip	:	90290-3659
Country	:	US
Telephone Number	:	310-924-5204
Fax Number	:

Provider Business Practice Location Address
First Line	:	2712 WILSHIRE BLVD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4706
Country	:	US
Telephone Number	:	424-744-8366
Fax Number	:

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

Provider Enumeration Date	:	11/30/2009
Last Update Date	:	04/27/2021

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