Provider Demographics
NPI:1245605690
Name:PERSOMA WELLNESS - A PROFESSIONAL ACUPUNCTURE CORPORATION
Entity Type:Organization
Organization Name:PERSOMA WELLNESS - A PROFESSIONAL ACUPUNCTURE CORPORATION
Other - Org Name:PERSOMA WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LODEN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:310-570-9723
Mailing Address - Street 1:777 SILVER SPUR RD # 112
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3633
Mailing Address - Country:US
Mailing Address - Phone:310-570-9723
Mailing Address - Fax:
Practice Address - Street 1:777 SILVER SPUR RD # 112
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3633
Practice Address - Country:US
Practice Address - Phone:310-570-9723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12304171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty