Provider Demographics
NPI:1316363492
Name:AVIDA CENTER ACUPUNCTURE CORP
Entity Type:Organization
Organization Name:AVIDA CENTER ACUPUNCTURE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:DIEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:VONG
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:619-890-8071
Mailing Address - Street 1:6191 CORNERSTONE CT E
Mailing Address - Street 2:STE 113
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4739
Mailing Address - Country:US
Mailing Address - Phone:619-890-8071
Mailing Address - Fax:858-550-0153
Practice Address - Street 1:6191 CORNERSTONE CT E
Practice Address - Street 2:STE 113
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4739
Practice Address - Country:US
Practice Address - Phone:619-890-8071
Practice Address - Fax:858-550-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10057171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty