Provider Demographics
NPI:1801217195
Name:TEOLOGO, ELAINE (LVN, CMT, LAC)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:TEOLOGO
Suffix:
Gender:F
Credentials:LVN, CMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1725
Mailing Address - Country:US
Mailing Address - Phone:310-987-1453
Mailing Address - Fax:
Practice Address - Street 1:1638 3RD AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-1725
Practice Address - Country:US
Practice Address - Phone:310-987-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10423225700000X
CA18490171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist