Provider Demographics
NPI:1083736508
Name:EDSTROM, INGER MARTA (LAC)
Entity type:Individual
Prefix:MS
First Name:INGER
Middle Name:MARTA
Last Name:EDSTROM
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 1:71 VIA ALMERIA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6515
Mailing Address - Country:US
Mailing Address - Phone:949-228-1381
Mailing Address - Fax:
Practice Address - Street 1:317 N EL CAMINO REAL STE 401
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2815
Practice Address - Country:US
Practice Address - Phone:760-635-0581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7012171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist