Provider Demographics
NPI:1194181438
Name:LAKE FOREST ACUPUNCTURE CLINIC
Entity Type:Organization
Organization Name:LAKE FOREST ACUPUNCTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-356-1065
Mailing Address - Street 1:23331 EL TORO RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4891
Mailing Address - Country:US
Mailing Address - Phone:949-446-8702
Mailing Address - Fax:
Practice Address - Street 1:23331 EL TORO RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4891
Practice Address - Country:US
Practice Address - Phone:949-446-8702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13504171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty