Provider Demographics
NPI:1285003541
Name:REVIDA ACUPUNCTURE AND WELLNESS
Entity Type:Organization
Organization Name:REVIDA ACUPUNCTURE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LISZT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LAC
Authorized Official - Phone:415-857-4464
Mailing Address - Street 1:411 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-2805
Mailing Address - Country:US
Mailing Address - Phone:415-857-4464
Mailing Address - Fax:415-750-3999
Practice Address - Street 1:1618 UNION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4507
Practice Address - Country:US
Practice Address - Phone:415-857-4464
Practice Address - Fax:415-750-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14731261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center