Provider Demographics
NPI:1700024650
Name:GEORGE-RYDBERG, SUSAN PATRICIA (LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:PATRICIA
Last Name:GEORGE-RYDBERG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:RYDBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 572051
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-2051
Mailing Address - Country:US
Mailing Address - Phone:818-347-9976
Mailing Address - Fax:818-340-3623
Practice Address - Street 1:6038 JUMILLA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5608
Practice Address - Country:US
Practice Address - Phone:818-347-9976
Practice Address - Fax:818-340-3623
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3304171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist