Provider Demographics
NPI:1457576290
Name:EIDE, SCOTT MICHAEL (LAC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:EIDE
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 1:2275 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-2523
Mailing Address - Country:US
Mailing Address - Phone:562-822-7639
Mailing Address - Fax:
Practice Address - Street 1:11 GOLDEN SHR
Practice Address - Street 2:SUITE 220
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4214
Practice Address - Country:US
Practice Address - Phone:562-495-5898
Practice Address - Fax:562-983-5454
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11147171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist