Provider Demographics
NPI:1588113096
Name:GUSTAFSON, BRUCE (LAC)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:GUSTAFSON
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 1:3218 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5928
Mailing Address - Country:US
Mailing Address - Phone:310-399-1040
Mailing Address - Fax:866-508-1580
Practice Address - Street 1:3218 18TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5928
Practice Address - Country:US
Practice Address - Phone:310-399-1040
Practice Address - Fax:866-508-1580
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17333171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist