Provider Demographics
NPI:1386723013
Name:DAHLSTROM, ERIC P (DC, LAC)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:P
Last Name:DAHLSTROM
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:P
Other - Last Name:DAHLSTROM, D.C., L.A.C. INC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, L AC
Mailing Address - Street 1:611 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2507
Mailing Address - Country:US
Mailing Address - Phone:310-451-2209
Mailing Address - Fax:
Practice Address - Street 1:611 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2507
Practice Address - Country:US
Practice Address - Phone:310-451-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26371111N00000X
CAAC10547171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA208035419OtherEIN
954854745OtherTIN #
DC26371Medicare ID - Type Unspecified