Provider Demographics
NPI:1154685774
Name:GUILLERMO, GREGORY DINO (LAC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DINO
Last Name:GUILLERMO
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 1:1547 E WASHINGTON AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-2558
Mailing Address - Country:US
Mailing Address - Phone:619-507-6783
Mailing Address - Fax:
Practice Address - Street 1:15644 POMERADO RD STE 400
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2418
Practice Address - Country:US
Practice Address - Phone:858-312-1672
Practice Address - Fax:858-312-6421
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13039171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist