Provider Demographics
NPI:1508071069
Name:ELLEGOOD, MARY HUNTER (L AC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HUNTER
Last Name:ELLEGOOD
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3442
Mailing Address - Country:US
Mailing Address - Phone:310-613-8375
Mailing Address - Fax:
Practice Address - Street 1:722 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3442
Practice Address - Country:US
Practice Address - Phone:310-613-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7257171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist