Provider Demographics
NPI:1265860340
Name:GRAVELLE, ROXANA G (L AC)
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:G
Last Name:GRAVELLE
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4742 HALBRENT AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2420
Mailing Address - Country:US
Mailing Address - Phone:310-909-4779
Mailing Address - Fax:
Practice Address - Street 1:12568 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5521
Practice Address - Country:US
Practice Address - Phone:424-888-0339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15150171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist