Provider Demographics
NPI:1063870822
Name:FLOURISHING MIND BODY WELLNESS CENTER, A COLLABORATIVE ACUPUNCTURE PC
Entity type:Organization
Organization Name:FLOURISHING MIND BODY WELLNESS CENTER, A COLLABORATIVE ACUPUNCTURE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:UEJO MARCHAND
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DIPL OM
Authorized Official - Phone:310-401-4065
Mailing Address - Street 1:1112 MONTANA AVE STE 528
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-7326
Mailing Address - Country:US
Mailing Address - Phone:310-401-4065
Mailing Address - Fax:
Practice Address - Street 1:1554 S SEPULVEDA BLVD STE 209
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3359
Practice Address - Country:US
Practice Address - Phone:310-401-4065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16926171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty