Provider Demographics
NPI:1780870162
Name:SANTICOLA, SHAYAN (L AC)
Entity type:Individual
Prefix:
First Name:SHAYAN
Middle Name:
Last Name:SANTICOLA
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 SPRUCE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302
Mailing Address - Country:US
Mailing Address - Phone:720-938-5829
Mailing Address - Fax:
Practice Address - Street 1:2595 SPRUCE ST
Practice Address - Street 2:SUITE B
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:720-938-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1179171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist