Provider Demographics
NPI:1053559153
Name:CHAN, EDITH Y (LAC)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:Y
Last Name:CHAN
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 1:4328 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3004
Mailing Address - Country:US
Mailing Address - Phone:415-668-1880
Mailing Address - Fax:415-668-2080
Practice Address - Street 1:4328 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3004
Practice Address - Country:US
Practice Address - Phone:415-668-1880
Practice Address - Fax:415-668-2080
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11420171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist