Provider Demographics
NPI:1952191033
Name:SHIVAKANTH, SUPREETH (LAC)
Entity type:Individual
Prefix:MR
First Name:SUPREETH
Middle Name:
Last Name:SHIVAKANTH
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 1:913 CAMELIA DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-5301
Mailing Address - Country:US
Mailing Address - Phone:551-339-9738
Mailing Address - Fax:
Practice Address - Street 1:3880 S BASCOM AVE STE 109
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2600
Practice Address - Country:US
Practice Address - Phone:209-340-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20341171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist