Provider Demographics
NPI:1033241930
Name:SORDEAN, JOHN RUSSELL (OMD LAC ND)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:SORDEAN
Suffix:
Gender:M
Credentials:OMD LAC ND
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:R
Other - Last Name:SORDEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OMD LAC ND
Mailing Address - Street 1:PO BOX 3998
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703
Mailing Address - Country:US
Mailing Address - Phone:510-220-2568
Mailing Address - Fax:510-849-1176
Practice Address - Street 1:1720 BANCROFT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703
Practice Address - Country:US
Practice Address - Phone:510-849-1176
Practice Address - Fax:510-849-1230
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2239171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist