Provider Demographics
NPI:1093809626
Name:CUSICK, PHILIP (LAC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:CUSICK
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 1:310 EUREKA SQ
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2652
Mailing Address - Country:US
Mailing Address - Phone:650-359-6046
Mailing Address - Fax:415-962-0605
Practice Address - Street 1:310 EUREKA SQ
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2652
Practice Address - Country:US
Practice Address - Phone:650-350-6046
Practice Address - Fax:415-962-0605
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7001171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist