Provider Demographics
NPI:1073198222
Name:TETZLOFF, CLEO AMELIA (LAC)
Entity Type:Individual
Prefix:
First Name:CLEO
Middle Name:AMELIA
Last Name:TETZLOFF
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92261-0043
Mailing Address - Country:US
Mailing Address - Phone:312-684-3504
Mailing Address - Fax:
Practice Address - Street 1:73255 EL PASEO STE 8
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4249
Practice Address - Country:US
Practice Address - Phone:312-684-3504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19063171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist