Provider Demographics
NPI:1760603740
Name:ANDERSON, LINDA RAE
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LINDA
Other - Middle Name:RAE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:33446 HWY 94
Mailing Address - Street 2:
Mailing Address - City:CAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:91906
Mailing Address - Country:US
Mailing Address - Phone:619-478-2900
Mailing Address - Fax:619-478-2500
Practice Address - Street 1:33446 HWY 94
Practice Address - Street 2:
Practice Address - City:CAMPO
Practice Address - State:CA
Practice Address - Zip Code:91906
Practice Address - Country:US
Practice Address - Phone:619-478-2900
Practice Address - Fax:619-478-2500
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4441171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist