Provider Demographics
NPI:1528517190
Name:SPORTS PERFORMANCE ACUPUNCTURE
Entity type:Organization
Organization Name:SPORTS PERFORMANCE ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVES
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:925-785-7364
Mailing Address - Street 1:1269 LINDELL DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-6040
Mailing Address - Country:US
Mailing Address - Phone:925-785-7364
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK RD STE 120
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-2039
Practice Address - Country:US
Practice Address - Phone:925-785-7364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16474171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty