Provider Demographics
NPI:1528281649
Name:EBBERT, KRISTIN MARIE (LAC)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:MARIE
Last Name:EBBERT
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 1:1616 MICHELTORENA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1624
Mailing Address - Country:US
Mailing Address - Phone:310-403-9604
Mailing Address - Fax:
Practice Address - Street 1:435 N. LARCHMONT BL.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004
Practice Address - Country:US
Practice Address - Phone:310-403-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11421171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist