Provider Demographics
NPI:1053522763
Name:BOUGOUKALOS, CYNTHIA M (LAC, DIPL AC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:BOUGOUKALOS
Suffix:
Gender:F
Credentials:LAC, DIPL AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11750 W SUNSET BLVD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2960
Mailing Address - Country:US
Mailing Address - Phone:310-266-4040
Mailing Address - Fax:
Practice Address - Street 1:11750 W. SUNSET BLVD. SUITE 501
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-2995
Practice Address - Country:US
Practice Address - Phone:310-266-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8896171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053522763OtherBLUE CROSS/BLUE SHIELD