Provider Demographics
NPI:1356587075
Name:CHALL, ETI A (LAC)
Entity type:Individual
Prefix:
First Name:ETI
Middle Name:A
Last Name:CHALL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ETI
Other - Middle Name:
Other - Last Name:DOMB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:4054 CENTRE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2634
Mailing Address - Country:US
Mailing Address - Phone:866-968-4325
Mailing Address - Fax:866-968-4325
Practice Address - Street 1:4054 CENTRE ST APT 1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2634
Practice Address - Country:US
Practice Address - Phone:866-968-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7996171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist