Provider Demographics
NPI:1588076525
Name:FANNING, DALE EDWARD (LAC)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:EDWARD
Last Name:FANNING
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 BLAKE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-2104
Mailing Address - Country:US
Mailing Address - Phone:206-979-4510
Mailing Address - Fax:888-522-6692
Practice Address - Street 1:1700 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-3402
Practice Address - Country:US
Practice Address - Phone:510-847-9706
Practice Address - Fax:888-522-6692
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-26
Last Update Date:2014-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15988171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist