Provider Demographics
NPI:1487063772
Name:VAN DER MEULEN, CHRISTINA (LAC)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:VAN DER MEULEN
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:PO BOX 4588
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-4588
Mailing Address - Country:US
Mailing Address - Phone:208-720-6513
Mailing Address - Fax:208-788-2287
Practice Address - Street 1:717 ELM ST.
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:ID
Practice Address - Zip Code:83313
Practice Address - Country:US
Practice Address - Phone:208-720-6513
Practice Address - Fax:208-788-2287
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU 140171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist