Provider Demographics
NPI:1487805834
Name:RADDER, DESTIN JOSEPH (LAC)
Entity type:Individual
Prefix:MR
First Name:DESTIN
Middle Name:JOSEPH
Last Name:RADDER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5320 MILITARY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-2149
Mailing Address - Country:US
Mailing Address - Phone:716-297-9379
Mailing Address - Fax:716-297-4638
Practice Address - Street 1:627 CENTER ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3804
Practice Address - Country:US
Practice Address - Phone:831-426-5044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12344171100000X
NY004488171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist