Healthcare Provider Details

I. General information

NPI: 1114229028
Provider Name (Legal Business Name): CONDE C FREEMAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CONDICT C FREEMAN LAC

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 CAMINO ALTO SUITE G
MILL VALLEY CA
94941-2254
US

IV. Provider business mailing address

131 CAMINO ALTO SUITE G
MILL VALLEY CA
94941-2254
US

V. Phone/Fax

Practice location:
  • Phone: 415-686-7615
  • Fax:
Mailing address:
  • Phone: 415-686-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCA13239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: