Provider Demographics
NPI:1285012161
Name:WARD, PHILLIP (LAC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WARD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12153 VENTURA BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2507
Mailing Address - Country:US
Mailing Address - Phone:323-376-2616
Mailing Address - Fax:
Practice Address - Street 1:4241 REDWOOD AVE
Practice Address - Street 2:#2214
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5619
Practice Address - Country:US
Practice Address - Phone:323-376-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16530171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist