Provider Demographics
NPI:1104124577
Name:SUSTAIN COMMUNITY ACUPUNCTURE
Entity type:Organization
Organization Name:SUSTAIN COMMUNITY ACUPUNCTURE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:619-358-9508
Mailing Address - Street 1:2537 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2807
Mailing Address - Country:US
Mailing Address - Phone:619-358-9508
Mailing Address - Fax:619-727-4543
Practice Address - Street 1:2537 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2807
Practice Address - Country:US
Practice Address - Phone:619-358-9508
Practice Address - Fax:619-727-4543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12894171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty