Provider Demographics
NPI:1245573732
Name:DEREVYANKO, VADIM (LAC)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:DEREVYANKO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 BRISTLECONE WAY
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551
Mailing Address - Country:US
Mailing Address - Phone:925-766-6101
Mailing Address - Fax:
Practice Address - Street 1:1718 HOLMES ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-6012
Practice Address - Country:US
Practice Address - Phone:925-766-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14899171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist