Provider Demographics
NPI:1154454213
Name:EKDAHL, THAD (LAC)
Entity Type:Individual
Prefix:MR
First Name:THAD
Middle Name:
Last Name:EKDAHL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4455 S PADRE ISLAND DR
Mailing Address - Street 2:SUITE 13
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-5101
Mailing Address - Country:US
Mailing Address - Phone:361-991-4672
Mailing Address - Fax:361-991-4673
Practice Address - Street 1:4455 S PADRE ISLAND DR
Practice Address - Street 2:SUITE 13
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-5101
Practice Address - Country:US
Practice Address - Phone:361-991-4672
Practice Address - Fax:361-991-4673
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00948171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist