Healthcare Provider Details

I. General information

NPI: 1033241930
Provider Name (Legal Business Name): JOHN RUSSELL SORDEAN OMD LAC ND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAY R SORDEAN OMD LAC ND

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 BANCROFT WAY
BERKELEY CA
94703
US

IV. Provider business mailing address

PO BOX 3998
BERKELEY CA
94703
US

V. Phone/Fax

Practice location:
  • Phone: 510-849-1176
  • Fax: 510-849-1230
Mailing address:
  • Phone: 510-220-2568
  • Fax: 510-849-1176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC2239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: