Provider Demographics
NPI:1447360813
Name:BAUER, MATTHEW DOUGLAS (LAC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DOUGLAS
Last Name:BAUER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
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Mailing Address - Street 1:3827 EMERALD AVE
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2904
Mailing Address - Country:US
Mailing Address - Phone:909-599-2347
Mailing Address - Fax:909-392-8608
Practice Address - Street 1:2186 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-4901
Practice Address - Country:US
Practice Address - Phone:909-599-2347
Practice Address - Fax:909-392-8608
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2668171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist