Provider Demographics
NPI:1235526005
Name:DAVIS, ELLEN GEHEBER (LAC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:GEHEBER
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8346 MANITOBA ST
Mailing Address - Street 2:APT 3
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8217
Mailing Address - Country:US
Mailing Address - Phone:310-490-3067
Mailing Address - Fax:
Practice Address - Street 1:11965 VENICE BLVD
Practice Address - Street 2:SUITE 407
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3979
Practice Address - Country:US
Practice Address - Phone:424-625-4228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16531171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist