Healthcare Provider Details

I. General information

NPI: 1154454213
Provider Name (Legal Business Name): THAD EKDAHL L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 S PADRE ISLAND DR SUITE 13
CORPUS CHRISTI TX
78411-5101
US

IV. Provider business mailing address

4455 S PADRE ISLAND DR SUITE 13
CORPUS CHRISTI TX
78411-5101
US

V. Phone/Fax

Practice location:
  • Phone: 361-991-4672
  • Fax: 361-991-4673
Mailing address:
  • Phone: 361-991-4672
  • Fax: 361-991-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00948
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: