Provider Demographics
NPI:1467642660
Name:KOMADA, MARY JO (LAC)
Entity Type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:
Last Name:KOMADA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JOEY
Other - Middle Name:
Other - Last Name:KOMADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:24445 HAWTHORNE BOULEVARD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6562
Mailing Address - Country:US
Mailing Address - Phone:310-617-6354
Mailing Address - Fax:310-257-9493
Practice Address - Street 1:24445 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6562
Practice Address - Country:US
Practice Address - Phone:310-617-6354
Practice Address - Fax:310-257-9493
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4660171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist