Provider Demographics
NPI:1568928430
Name:KELSO BINZAK, MICHELLE (LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KELSO BINZAK
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 1:6760 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611
Mailing Address - Country:US
Mailing Address - Phone:310-529-6891
Mailing Address - Fax:
Practice Address - Street 1:233 S MARKET ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2218
Practice Address - Country:US
Practice Address - Phone:310-529-6891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
HI1253171100000X
CA19231171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist