Healthcare Provider Details

I. General information

NPI: 1487805834
Provider Name (Legal Business Name): DESTIN JOSEPH RADDER L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 CENTER ST
SANTA CRUZ CA
95060-3804
US

IV. Provider business mailing address

5320 MILITARY RD SUITE 104
LEWISTON NY
14092-2149
US

V. Phone/Fax

Practice location:
  • Phone: 831-426-5044
  • Fax:
Mailing address:
  • Phone: 716-297-9379
  • Fax: 716-297-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number12344
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number004488
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: