Provider Demographics
NPI:1356866396
Name:MONTES DE OCA, CARLYN MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:CARLYN
Middle Name:MARIE
Last Name:MONTES DE OCA
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:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:FOREST KNOLLS
Mailing Address - State:CA
Mailing Address - Zip Code:94933-0312
Mailing Address - Country:US
Mailing Address - Phone:415-306-1853
Mailing Address - Fax:
Practice Address - Street 1:130 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2449
Practice Address - Country:US
Practice Address - Phone:415-306-1853
Practice Address - Fax:415-306-1853
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10021171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist