SAN PEDRO HEALING ARTS MEDICAL CLINIC INC

Provider Demographics

• NPI: 1487735221
• Name: SAN PEDRO HEALING ARTS MEDICAL CLINIC INC
• Entity type: Organization
• Organization Name: SAN PEDRO HEALING ARTS MEDICAL CLINIC INC
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: MARIA
• Authorized Official - Middle Name: E
• Authorized Official - Last Name: BAEZ
• Authorized Official - Credentials: OMD LAC
• Authorized Official - Phone: 310-547-2197
• Mailing Address - Street 1: 1366 W 7TH ST
• Mailing Address - Street 2: SUITE 4B
• Mailing Address - City: SAN PEDRO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 90732-3500
• Mailing Address - Country: US
• Mailing Address - Phone: 310-547-2197
• Mailing Address - Fax: 310-547-9532
• Practice Address - Street 1: 1366 W 7TH ST
• Practice Address - Street 2: SUITE 4B
• Practice Address - City: SAN PEDRO
• Practice Address - State: CA
• Practice Address - Zip Code: 90732-3500
• Practice Address - Country: US
• Practice Address - Phone: 310-547-2197
• Practice Address - Fax: 310-547-9532
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-10-18
• Last Update Date: 2016-10-11

Provider Licenses

State	License ID	Taxonomies
CA	MFC45939	106H00000X
CA	LMFT81399	106H00000X
CA	LMFT86500	106H00000X
CA	DC27614	111N00000X
CA	DC 21667	111N00000X
CA	DC33346	111NX0800X
CA	AC10137	171100000X
CA	AC9270	171100000X
CA	PT2838	174400000X
CA	PA 18999	363A00000X
CA	PA 21347	363A00000X
CA	G67514	207Q00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	106H00000X	Behavioral Health & Social Service Providers	Marriage & Family Therapist		Group - Multi-Specialty
No	111N00000X	Chiropractic Providers	Chiropractor		Group - Multi-Specialty
No	111NX0800X	Chiropractic Providers	Chiropractor	Orthopedic	Group - Multi-Specialty
No	171100000X	Other Service Providers	Acupuncturist		Group - Multi-Specialty
No	174400000X	Other Service Providers	Specialist		Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	G67514	Other	MEDICAL DOCTOR
CA	PA 18999	Other	PHYSICAN ASSISTANT
CA	DC 21667	Other	CHIROPRACTOR
CA	MFC45939	Other	MARRIAGE & FAMILY COUNSELING
CA	PT 17929	Other	PHYSICAL THERAPY
CA	AC10137	Other	ACUPUNCTURE
CA	AC9270	Other	ACUPUNCTURE
CA	DC27614	Other	CHIROPRACTOR
CA	DC33346	Other	CHIROPRACTIC
CA	PT2838	Other	PHYSICAL THERAPY
CA	LMFT81399	Other	MARRIAGE & FAMILY COUNSELING
CA	LMFT86500	Other	MARRIAGE & FAMILY COUNSELING
CA	PA 21347	Other	PHYSICIAN ASSISTANT