Provider Demographics
NPI:1053450189
Name:LOS ANGELES CENTER FOR INTEGRATED MEDICINE
Entity Type:Organization
Organization Name:LOS ANGELES CENTER FOR INTEGRATED MEDICINE
Other - Org Name:CENTER FOR ORIENTAL AND INTEGRATED MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PENDING GRADUATION
Authorized Official - Phone:310-497-1774
Mailing Address - Street 1:468 N CAMDEN DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4507
Mailing Address - Country:US
Mailing Address - Phone:310-497-1774
Mailing Address - Fax:
Practice Address - Street 1:468 N CAMDEN DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4507
Practice Address - Country:US
Practice Address - Phone:310-497-1774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING GRADUATION171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty