Provider Demographics
NPI:1164730701
Name:KANZAWA, TRACI (LAC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:KANZAWA
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 1:220 MONTGOMERY ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-3402
Mailing Address - Country:US
Mailing Address - Phone:415-677-9900
Mailing Address - Fax:415-358-5803
Practice Address - Street 1:220 MONTGOMERY ST
Practice Address - Street 2:SUITE 305
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-3402
Practice Address - Country:US
Practice Address - Phone:415-677-9900
Practice Address - Fax:415-358-5803
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13773171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC13773OtherACUPUNCTURE LICENSE #