Provider Demographics
NPI:1104958313
Name:FEDER, EDMOND DAVID (LAC, QME)
Entity type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:DAVID
Last Name:FEDER
Suffix:
Gender:M
Credentials:LAC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 604
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5201
Mailing Address - Country:US
Mailing Address - Phone:323-933-2444
Mailing Address - Fax:
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:SUITE 604
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-933-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7946171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA043615829OtherPROVIDER ID