Provider Demographics
NPI:1598938631
Name:UPSHAW, LISA HOLLINGSWORTH (DC, L AC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:HOLLINGSWORTH
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:DC, L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 LINCOLN BLVD
Mailing Address - Street 2:STE 225
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2827
Mailing Address - Country:US
Mailing Address - Phone:310-396-3635
Mailing Address - Fax:877-767-6217
Practice Address - Street 1:614 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4801
Practice Address - Country:US
Practice Address - Phone:877-767-6217
Practice Address - Fax:877-767-6217
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11018171100000X
CA29832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC11018OtherLICENSE