Provider Demographics
NPI:1508007915
Name:WIDRIN, COLETTE (LAC)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:WIDRIN
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 1:714 1/2 N EDINBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-7004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 1/2 N EDINBURGH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-7004
Practice Address - Country:US
Practice Address - Phone:310-492-5014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2015-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14106171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist