Provider Demographics
NPI:1679298178
Name:LANGE, SUSAN (OMD, LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 ALAMO PINTADO RD.,
Mailing Address - Street 2:STE 3-253
Mailing Address - City:SOLVANG,
Mailing Address - State:CA
Mailing Address - Zip Code:93463
Mailing Address - Country:US
Mailing Address - Phone:310-395-9525
Mailing Address - Fax:
Practice Address - Street 1:506 SANTA MONICA BLVD.
Practice Address - Street 2:STE 227
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401
Practice Address - Country:US
Practice Address - Phone:310-395-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC2282171100000X
CAAC3336171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist