Provider Demographics
NPI:1669723565
Name:JOHNSON, VICTORIA IRENE (LAC)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:IRENE
Last Name:JOHNSON
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 1:3804 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5354
Mailing Address - Country:US
Mailing Address - Phone:510-338-6952
Mailing Address - Fax:
Practice Address - Street 1:3804 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5354
Practice Address - Country:US
Practice Address - Phone:510-338-6952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14643171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist