Provider Demographics
NPI:1083983951
Name:DONOVAN, VILA M (LAC)
Entity Type:Individual
Prefix:MS
First Name:VILA
Middle Name:M
Last Name:DONOVAN
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 1:19751 GRAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:TOPANGA
Mailing Address - State:CA
Mailing Address - Zip Code:90290-3313
Mailing Address - Country:US
Mailing Address - Phone:831-915-7041
Mailing Address - Fax:
Practice Address - Street 1:19751 GRAND VIEW DR
Practice Address - Street 2:
Practice Address - City:TOPANGA
Practice Address - State:CA
Practice Address - Zip Code:90290-3313
Practice Address - Country:US
Practice Address - Phone:831-915-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist