Provider Demographics
NPI:1164087623
Name:MAURO, CARROL D (LAC)
Entity Type:Individual
Prefix:
First Name:CARROL
Middle Name:D
Last Name:MAURO
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 1:7644 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-3815
Mailing Address - Country:US
Mailing Address - Phone:510-710-0384
Mailing Address - Fax:
Practice Address - Street 1:5737 THORNHILL DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2144
Practice Address - Country:US
Practice Address - Phone:510-339-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11546171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist