Provider Demographics
NPI:1265983324
Name:BACK, ANNA (LAC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BACK
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 1:2328 3RD ST APT 14
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3460
Mailing Address - Country:US
Mailing Address - Phone:310-602-9518
Mailing Address - Fax:
Practice Address - Street 1:823 W 9TH ST # 815
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3603
Practice Address - Country:US
Practice Address - Phone:310-602-9518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17369171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist