Provider Demographics
NPI:1265866214
Name:CORVERA, LOUIS DANIEL (LAC)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:DANIEL
Last Name:CORVERA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 VISTA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2529
Mailing Address - Country:US
Mailing Address - Phone:619-750-6548
Mailing Address - Fax:
Practice Address - Street 1:4711 VISTA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2529
Practice Address - Country:US
Practice Address - Phone:619-750-6548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14162171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist