Provider Demographics
NPI:1205427242
Name:IDYLLWILD COMMUNITY ACUPUNCTURE & BODYWORK, INC.
Entity type:Organization
Organization Name:IDYLLWILD COMMUNITY ACUPUNCTURE & BODYWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:859-396-0469
Mailing Address - Street 1:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:IDYLLWILD
Mailing Address - State:CA
Mailing Address - Zip Code:92549-2421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54445 N CIRCLE DRIVE, SUITE A
Practice Address - Street 2:
Practice Address - City:IDYLLWILD
Practice Address - State:CA
Practice Address - Zip Code:92549
Practice Address - Country:US
Practice Address - Phone:859-396-0469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty