Provider Demographics
NPI:1225682040
Name:RA, DAHAE
Entity Type:Individual
Prefix:
First Name:DAHAE
Middle Name:
Last Name:RA
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 1:16607 HALLDALE AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5474
Mailing Address - Country:US
Mailing Address - Phone:310-867-0702
Mailing Address - Fax:
Practice Address - Street 1:16607 HALLDALE AVE APT 206
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-5474
Practice Address - Country:US
Practice Address - Phone:310-867-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15463171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist