Provider Demographics
NPI:1972632867
Name:RUCKER, VIVEKA SARAH (LAC)
Entity type:Individual
Prefix:
First Name:VIVEKA
Middle Name:SARAH
Last Name:RUCKER
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 1:24007 VENTURA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-2549
Mailing Address - Country:US
Mailing Address - Phone:818-554-5418
Mailing Address - Fax:818-225-8597
Practice Address - Street 1:24007 VENTURA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-2549
Practice Address - Country:US
Practice Address - Phone:818-554-5418
Practice Address - Fax:818-225-8597
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9004133NN1002X, 171100000X
CA6386133NN1002X, 171100000X
CA8942133NN1002X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90-0126489OtherTAX I.D.#