Provider Demographics
NPI:1396189304
Name:RAISDANA, DELARAM (LAC)
Entity Type:Individual
Prefix:
First Name:DELARAM
Middle Name:
Last Name:RAISDANA
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 1:2900 BRISTOL ST STE G104
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7912
Mailing Address - Country:US
Mailing Address - Phone:949-373-5829
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE G104
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7912
Practice Address - Country:US
Practice Address - Phone:949-373-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-20
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15322171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist