MEDICARE: MS. DIANE BLACK 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	AC3223	CA

General Provider Information

NPI Number	:	1962533885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE BLACK L.AC.

Provider Business Mailing Address
First Line	:	506 SANTA MONICA BLVD
Second Line	:	SUITE 317
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2434
Country	:	US
Telephone Number	:	310-458-0666
Fax Number	:	310-451-0670

Provider Business Practice Location Address
First Line	:	506 SANTA MONICA BLVD
Second Line	:	SUITE 317
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2434
Country	:	US
Telephone Number	:	310-458-0666
Fax Number	:	310-451-0670

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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Directions to “ MS. DIANE BLACK L.AC.” Practice Location

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