Provider Demographics
NPI:1821445214
Name:CHAVEZ, ALICIA (LAC, MTOM)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:LAC, MTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5363 BALBOA BLVD STE 436
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2840
Mailing Address - Country:US
Mailing Address - Phone:424-653-6241
Mailing Address - Fax:
Practice Address - Street 1:5363 BALBOA BLVD STE 436
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2840
Practice Address - Country:US
Practice Address - Phone:424-653-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist