Provider Demographics
NPI:1770962193
Name:SIMPER, CARISSA (LAC)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:SIMPER
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 1:2131 CAPITOL AVE
Mailing Address - Street 2:307
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 CAPITOL AVE
Practice Address - Street 2:307
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5755
Practice Address - Country:US
Practice Address - Phone:916-444-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16675171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist