Provider Demographics
NPI:1508399569
Name:SAN DIEGO SPORTS ACUPUNCTURE, INC
Entity Type:Organization
Organization Name:SAN DIEGO SPORTS ACUPUNCTURE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:858-255-8070
Mailing Address - Street 1:5465 MOREHOUSE DR
Mailing Address - Street 2:100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4700
Mailing Address - Country:US
Mailing Address - Phone:858-255-8070
Mailing Address - Fax:858-750-2428
Practice Address - Street 1:5465 MOREHOUSE DR
Practice Address - Street 2:100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4700
Practice Address - Country:US
Practice Address - Phone:858-255-8070
Practice Address - Fax:858-750-2428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14401171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty