Provider Demographics
NPI:1205183134
Name:MATSUMOTO, TAMMY (LAC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:MATSUMOTO
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 1:2383 LOMITA BLVD
Mailing Address - Street 2:#111
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1446
Mailing Address - Country:US
Mailing Address - Phone:818-577-5762
Mailing Address - Fax:
Practice Address - Street 1:2383 LOMITA BLVD
Practice Address - Street 2:#111
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-1446
Practice Address - Country:US
Practice Address - Phone:818-577-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9369171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist