Provider Demographics
NPI:1649456625
Name:ZIMMERMAN, GREGORY DONALD (LAC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:DONALD
Last Name:ZIMMERMAN
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:PO BOX 62965
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602
Mailing Address - Country:US
Mailing Address - Phone:949-677-8498
Mailing Address - Fax:
Practice Address - Street 1:1110 ROOSEVELT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-3686
Practice Address - Country:US
Practice Address - Phone:949-677-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 6280171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist