Provider Demographics
NPI:1336649821
Name:LOKTENKO-BLACK, INNA (LAC)
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:LOKTENKO-BLACK
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 1:626 CHARLESTON PL
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-3784
Mailing Address - Country:US
Mailing Address - Phone:805-672-0349
Mailing Address - Fax:
Practice Address - Street 1:1601 CARMEN DR STE 216
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3167
Practice Address - Country:US
Practice Address - Phone:805-947-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17827171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist