Provider Demographics
NPI:1083837363
Name:GOLDBERG, TINA (L AC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43443 STONY HILL ST
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-9331
Mailing Address - Country:US
Mailing Address - Phone:760-774-5439
Mailing Address - Fax:760-340-1991
Practice Address - Street 1:73661 HIGHWAY 111
Practice Address - Street 2:SUITE F
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4012
Practice Address - Country:US
Practice Address - Phone:760-774-5439
Practice Address - Fax:760-340-1991
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACS2717171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21355ZOtherBLUE SHIELD PROVIDER #