1508034992 NPI number — MS. KRISTELYN BROOKS WACHNER L.AC.

Table of content: MS. KRISTELYN BROOKS WACHNER L.AC. (NPI 1508034992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508034992 NPI number — MS. KRISTELYN BROOKS WACHNER L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WACHNER
Provider First Name:
KRISTELYN
Provider Middle Name:
BROOKS
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508034992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4352 MARLBOROUGH AVE
Provider Second Line Business Mailing Address:
APARTMENT 5
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92105-1181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-398-5157
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-6970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-398-5157
Provider Business Practice Location Address Fax Number:
619-702-7609
Provider Enumeration Date:
02/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  11690 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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