Provider Demographics
NPI:1477854446
Name:DIVELEY, GENO PALMA (LAC)
Entity Type:Individual
Prefix:MR
First Name:GENO
Middle Name:PALMA
Last Name:DIVELEY
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 1:3231 BUSINESS PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8530
Mailing Address - Country:US
Mailing Address - Phone:760-975-1230
Mailing Address - Fax:
Practice Address - Street 1:3231 BUSINESS PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8530
Practice Address - Country:US
Practice Address - Phone:760-975-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13924171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist