Healthcare Provider Details

I. General information

NPI: 1760500466
Provider Name (Legal Business Name): PAUL ALRIK GUSTAFSON L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 WALNUT ST SUITE E
BERKELEY CA
94709-1563
US

IV. Provider business mailing address

1859 YOSEMITE ROAD
BERKELEY CA
94707
US

V. Phone/Fax

Practice location:
  • Phone: 510-332-0596
  • Fax:
Mailing address:
  • Phone: 510-332-0596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC10516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: