Provider Demographics
NPI:1164970265
Name:STOCK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:STOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSOM, LAC
Mailing Address - Street 1:50 GUILFORD RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-3805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 BROWN AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3902
Practice Address - Country:US
Practice Address - Phone:510-359-4102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17130171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist