Provider Demographics
NPI:1124560024
Name:TAMBOLI, KAVITA
Entity Type:Individual
Prefix:
First Name:KAVITA
Middle Name:
Last Name:TAMBOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41161 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-3839
Mailing Address - Country:US
Mailing Address - Phone:510-449-7550
Mailing Address - Fax:
Practice Address - Street 1:4086 BAY ST # A
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4205
Practice Address - Country:US
Practice Address - Phone:510-449-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17139171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist