Healthcare Provider Details

I. General information

NPI: 1386222164
Provider Name (Legal Business Name): DR. TAGE SEBASTIAN KVERNELAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828B N LA BREA AVE
LOS ANGELES CA
90038-3341
US

IV. Provider business mailing address

248 N VAN NESS AVE APT 7
LOS ANGELES CA
90004-3951
US

V. Phone/Fax

Practice location:
  • Phone: 310-750-9887
  • Fax:
Mailing address:
  • Phone: 310-750-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number34516
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number34516
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: