Provider Demographics
NPI:1518449370
Name:CHAN, CARLA S (LAC)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:S
Last Name:CHAN
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 1:2009 MCGEE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1448
Mailing Address - Country:US
Mailing Address - Phone:415-519-5449
Mailing Address - Fax:
Practice Address - Street 1:3150 18TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2074
Practice Address - Country:US
Practice Address - Phone:415-519-5449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18112171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist