Provider Demographics
NPI:1023494259
Name:VAN, MICHAEL (LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VAN
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 1:9901 INDIANA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5416
Mailing Address - Country:US
Mailing Address - Phone:951-343-2848
Mailing Address - Fax:951-343-2969
Practice Address - Street 1:16550 CATALONIA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-8701
Practice Address - Country:US
Practice Address - Phone:951-343-2848
Practice Address - Fax:951-343-2969
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9368171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist