Provider Demographics
NPI:1740683127
Name:SHAHAM, SHLOMTZION MIRI (LAC)
Entity type:Individual
Prefix:
First Name:SHLOMTZION
Middle Name:MIRI
Last Name:SHAHAM
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 1:781 STONE LN
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-4453
Mailing Address - Country:US
Mailing Address - Phone:415-535-4116
Mailing Address - Fax:
Practice Address - Street 1:781 STONE LN
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-4453
Practice Address - Country:US
Practice Address - Phone:650-830-1396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
CA15927171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133N00000XDietary & Nutritional Service ProvidersNutritionist