MEDICARE: DR. AMANDA COHEN DAOM, 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	CA15953	CA
2	261QM2500X	Medical Specialty Clinic/Center	CA15953	CA
3	261QP2300X	Primary Care Clinic/Center	CA15953	CA
4	208D00000X	General Practice Physician	CA15953	CA

General Provider Information

NPI Number	:	1780003350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA COHEN DAOM, L.AC

Provider Business Mailing Address
First Line	:	3036 GLENDALE BLVD.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039
Country	:	US
Telephone Number	:	424-835-0884
Fax Number	:	323-978-5158

Provider Business Practice Location Address
First Line	:	3036 GLENDALE BLVD.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039
Country	:	US
Telephone Number	:	424-835-0884
Fax Number	:	323-978-5158

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

Provider Enumeration Date	:	04/10/2014
Last Update Date	:	06/26/2020

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