Provider Demographics
NPI:1144863598
Name:DISALVO, ANTHONY (LAC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DISALVO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17203 VENTURA BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4054
Mailing Address - Country:US
Mailing Address - Phone:818-650-8555
Mailing Address - Fax:
Practice Address - Street 1:17203 VENTURA BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4054
Practice Address - Country:US
Practice Address - Phone:818-650-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18694171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist