Provider Demographics
NPI:1255454351
Name:TAN, ANNIE ENLI (LAC)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:ENLI
Last Name:TAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15103 SHINING STAR LN
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-1994
Mailing Address - Country:US
Mailing Address - Phone:510-483-7764
Mailing Address - Fax:
Practice Address - Street 1:1441 FRANKLIN ST STE 203
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3219
Practice Address - Country:US
Practice Address - Phone:510-420-5787
Practice Address - Fax:510-420-5787
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10188171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist