Provider Demographics
NPI:1184017873
Name:TY-KISERA, MERINA (LAC)
Entity Type:Individual
Prefix:
First Name:MERINA
Middle Name:
Last Name:TY-KISERA
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 1:2488 NEWPORT BLVD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2488 NEWPORT BLVD
Practice Address - Street 2:SUITE A-1
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5196
Practice Address - Country:US
Practice Address - Phone:949-940-6373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16216171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist