MEDICARE: PACIFIC CENTER OF HEALTH AND ACUPUNCTURE, INC.

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	AC2209	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ66200Z	OTHER	CA	BLUE SHIELD ID

General Provider Information

NPI Number	:	1932131539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC CENTER OF HEALTH AND ACUPUNCTURE, INC.

Provider Business Mailing Address
First Line	:	2615 CAMINO DEL RIO S. #201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108
Country	:	US
Telephone Number	:	619-542-0884
Fax Number	:	619-542-0949

Provider Business Practice Location Address
First Line	:	2615 CAMINO DEL RIO S. #201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108
Country	:	US
Telephone Number	:	619-542-0884
Fax Number	:	619-542-0949

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	TIFFANY ANDERSEN
Credential	:	BS
Telephone Number	:	619-542-0884

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	01/13/2012

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