Provider Demographics
NPI:1225184534
Name:STARK, ALICIA MARIE (ATC)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:MARIE
Last Name:STARK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3868 KENDALL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6504
Mailing Address - Country:US
Mailing Address - Phone:619-417-1563
Mailing Address - Fax:
Practice Address - Street 1:5998 ALCALA PARK
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2476
Practice Address - Country:US
Practice Address - Phone:619-260-8895
Practice Address - Fax:619-260-4742
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer