Provider Demographics
NPI:1235157884
Name:KRETH, ELISA MARIE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:MARIE
Last Name:KRETH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12264 EL CAMINO REAL
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3060
Mailing Address - Country:US
Mailing Address - Phone:858-481-0303
Mailing Address - Fax:858-481-9797
Practice Address - Street 1:12264 EL CAMINO REAL
Practice Address - Street 2:SUITE 108
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3060
Practice Address - Country:US
Practice Address - Phone:858-481-0303
Practice Address - Fax:858-481-9797
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA10637171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist