Provider Demographics
NPI:1437988748
Name:DE OLIVEIRA DUTRA VIDAL BARBOSA, DEBORA (LAC)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:
Last Name:DE OLIVEIRA DUTRA VIDAL BARBOSA
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 1:3220 S WESTERN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-5347
Mailing Address - Country:US
Mailing Address - Phone:626-344-5335
Mailing Address - Fax:
Practice Address - Street 1:3220 S WESTERN AVE STE 1
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5347
Practice Address - Country:US
Practice Address - Phone:626-344-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20094171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist