Provider Demographics
NPI:1194943183
Name:CRISTDAHL, ILENE L (MD LAC)
Entity type:Individual
Prefix:
First Name:ILENE
Middle Name:L
Last Name:CRISTDAHL
Suffix:
Gender:F
Credentials:MD LAC
Other - Prefix:
Other - First Name:ILENE
Other - Middle Name:
Other - Last Name:DAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND, LAC
Mailing Address - Street 1:101 PROVIDENCE MINE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2939
Mailing Address - Country:US
Mailing Address - Phone:530-470-8707
Mailing Address - Fax:530-852-4996
Practice Address - Street 1:101 PROVIDENCE MINE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2939
Practice Address - Country:US
Practice Address - Phone:530-470-8707
Practice Address - Fax:530-852-4996
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2301171100000X
CAND143175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist