Provider Demographics
NPI:1316290075
Name:MACK, VALERIE ALIDA (LAC)
Entity type:Individual
Prefix:MRS
First Name:VALERIE
Middle Name:ALIDA
Last Name:MACK
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 1:1646 FRANKLIN ST APT D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4223
Mailing Address - Country:US
Mailing Address - Phone:213-924-1787
Mailing Address - Fax:
Practice Address - Street 1:2001 S BARRINGTON AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5363
Practice Address - Country:US
Practice Address - Phone:310-473-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15032171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist