Healthcare Provider Details

I. General information

NPI: 1508386087
Provider Name (Legal Business Name): JOANNE KHA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 S NOVATO BLVD STE E
NOVATO CA
94947-4184
US

IV. Provider business mailing address

1931 TIOGA LOOP
HERCULES CA
94547-2794
US

V. Phone/Fax

Practice location:
  • Phone: 510-621-7671
  • Fax: 510-201-3139
Mailing address:
  • Phone: 510-621-7671
  • Fax: 510-201-3139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17603
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: