Provider Demographics
NPI:1104000165
Name:FUSCO, CAROL (LAC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:FUSCO
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:PO BOX 2622
Mailing Address - Street 2:
Mailing Address - City:EL GRANADA
Mailing Address - State:CA
Mailing Address - Zip Code:94018-2622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1330 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3912
Practice Address - Country:US
Practice Address - Phone:415-826-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2315171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist