Provider Demographics
NPI:1043340037
Name:ELLITHORPE, THERESA KUNI (LAC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:KUNI
Last Name:ELLITHORPE
Suffix:
Gender:F
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:P.O. BOX 81603
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92138
Mailing Address - Country:US
Mailing Address - Phone:619-291-2462
Mailing Address - Fax:619-291-9242
Practice Address - Street 1:2304 SAN DIEGO AVE.
Practice Address - Street 2:SUITE C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-200-5280
Practice Address - Fax:619-291-9242
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6050171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist