Provider Demographics
NPI:1275291692
Name:TAE, SARAH J (LAC)
Entity Type:Individual
Prefix:MS
First Name:SARAH
Middle Name:J
Last Name:TAE
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:PO BOX 1571
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95461-1571
Mailing Address - Country:US
Mailing Address - Phone:415-797-8299
Mailing Address - Fax:
Practice Address - Street 1:18990 COYOTE VALLEY RD
Practice Address - Street 2:
Practice Address - City:HIDDEN VALLEY LAKE
Practice Address - State:CA
Practice Address - Zip Code:95467-8337
Practice Address - Country:US
Practice Address - Phone:415-797-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
CA10945171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty