Provider Demographics
NPI:1710397971
Name:WITFOTH, INGA (LAC)
Entity Type:Individual
Prefix:
First Name:INGA
Middle Name:
Last Name:WITFOTH
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:PO BOX 3243
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90632-3243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 W VALENCIA DR
Practice Address - Street 2:SUITE P
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4046
Practice Address - Country:US
Practice Address - Phone:714-879-9691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9541171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist