Provider Demographics
NPI:1609812684
Name:FORSBERG, LARRY C (LAC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:C
Last Name:FORSBERG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 E. 23RD ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601
Mailing Address - Country:US
Mailing Address - Phone:415-370-3839
Mailing Address - Fax:415-242-2411
Practice Address - Street 1:337 WEST PORTAL AV.
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127
Practice Address - Country:US
Practice Address - Phone:415-370-3839
Practice Address - Fax:415-242-2411
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3022171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0030220Medicaid