Provider Demographics
NPI:1922356781
Name:PETTITT, SARA (LAC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:PETTITT
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 1:14650 AVIATION BLVD STE 225
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6666
Mailing Address - Country:US
Mailing Address - Phone:310-489-5578
Mailing Address - Fax:310-536-9996
Practice Address - Street 1:14650 AVIATION BLVD STE 225
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6666
Practice Address - Country:US
Practice Address - Phone:310-489-5578
Practice Address - Fax:310-536-9996
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9640171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist