Provider Demographics
NPI:1891482519
Name:MYODETOX CALIFORNIA PC INC.
Entity Type:Organization
Organization Name:MYODETOX CALIFORNIA PC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCACCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-327-0019
Mailing Address - Street 1:8354 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8354 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4313
Practice Address - Country:US
Practice Address - Phone:323-831-2455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty