Provider Demographics
NPI:1114387545
Name:KILLPACK, MARIEGRACE (LAC)
Entity Type:Individual
Prefix:
First Name:MARIEGRACE
Middle Name:
Last Name:KILLPACK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:KILLPACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:4125 24TH ST
Mailing Address - Street 2:# 3
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3642
Mailing Address - Country:US
Mailing Address - Phone:415-706-9324
Mailing Address - Fax:
Practice Address - Street 1:2000 VAN NESS AVE
Practice Address - Street 2:STE. 708
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-3023
Practice Address - Country:US
Practice Address - Phone:415-890-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16859171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist