Provider Demographics
NPI:1538639653
Name:FELLUS, OLIVIA (LAC, DIPLOM)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:FELLUS
Suffix:
Gender:F
Credentials:LAC, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W HARBOR DR UNIT 1404
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3436 UTAH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-4110
Practice Address - Country:US
Practice Address - Phone:619-987-8967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17154171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist