Provider Demographics
NPI:1659599223
Name:THOMAS, ENID ROSE (LAC)
Entity Type:Individual
Prefix:
First Name:ENID
Middle Name:ROSE
Last Name:THOMAS
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 1:3023 BUNKER HILL ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5706
Mailing Address - Country:US
Mailing Address - Phone:619-548-6733
Mailing Address - Fax:
Practice Address - Street 1:3023 BUNKER HILL ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5706
Practice Address - Country:US
Practice Address - Phone:619-548-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-21
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8407171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-5348923Medicare UPIN