Provider Demographics
NPI:1982816906
Name:FREED, ELLIOTT J (LAC)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:J
Last Name:FREED
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-3411
Mailing Address - Country:US
Mailing Address - Phone:707-584-7799
Mailing Address - Fax:
Practice Address - Street 1:5300 SNYDER LN
Practice Address - Street 2:SUITE C
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2915
Practice Address - Country:US
Practice Address - Phone:707-584-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9835171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist