Provider Demographics
NPI:1386222164
Name:KVERNELAND, TAGE SEBASTIAN
Entity Type:Individual
Prefix:DR
First Name:TAGE SEBASTIAN
Middle Name:
Last Name:KVERNELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 N VAN NESS AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3951
Mailing Address - Country:US
Mailing Address - Phone:310-750-9887
Mailing Address - Fax:
Practice Address - Street 1:828B N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3341
Practice Address - Country:US
Practice Address - Phone:310-750-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34516111NN1001X, 111NX0100X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NX0100XChiropractic ProvidersChiropractorOccupational Health