Provider Demographics
NPI:1568539179
Name:CANDELARIA, IDA DESOLINA (LAC)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:DESOLINA
Last Name:CANDELARIA
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 1:3341 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-7203
Mailing Address - Country:US
Mailing Address - Phone:619-267-1400
Mailing Address - Fax:
Practice Address - Street 1:4514 BONITA RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1427
Practice Address - Country:US
Practice Address - Phone:619-267-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AC 5540171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist