MEDICARE: LISA EDENS-TAN ND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175F00000X	Naturopath	ND988	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ND988	OTHER	CA	DEPARTMENT OF CONSUMER AFFAIRS

General Provider Information

NPI Number	:	1316434442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA EDENS-TAN ND

Provider Business Mailing Address
First Line	:	623 S SANDERSON WAY
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4537
Country	:	US
Telephone Number	:	925-209-5966
Fax Number	:

Provider Business Practice Location Address
First Line	:	647 N MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-3219
Country	:	US
Telephone Number	:	925-209-5966
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2018
Last Update Date	:	02/04/2020

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