Provider Demographics
NPI:1609172816
Name:BYNUM, ELAINE KATHRYN (LAC, CMT)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:KATHRYN
Last Name:BYNUM
Suffix:
Gender:F
Credentials:LAC, CMT
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:BYNUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, CMT
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93483-0888
Mailing Address - Country:US
Mailing Address - Phone:805-722-5847
Mailing Address - Fax:
Practice Address - Street 1:129 N HALCYON RD STE H
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2587
Practice Address - Country:US
Practice Address - Phone:805-722-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12292171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist