Provider Demographics
NPI:1588101752
Name:KNUDTSON, MARGUERITE VANCE (LAC)
Entity type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:VANCE
Last Name:KNUDTSON
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 1:4096 PIEDMONT AVE
Mailing Address - Street 2:#212
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5221
Mailing Address - Country:US
Mailing Address - Phone:510-575-0609
Mailing Address - Fax:
Practice Address - Street 1:3441 GOLDEN GATE WAY
Practice Address - Street 2:SUITE H
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4581
Practice Address - Country:US
Practice Address - Phone:510-575-0609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17252171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist