Provider Demographics
NPI:1710370655
Name:VANDERSTOCK, KRISTINE (LAC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:
Last Name:VANDERSTOCK
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 1:855 S MAIN AVE # K104
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 E ALVARADO ST
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-2049
Practice Address - Country:US
Practice Address - Phone:760-521-3589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13894171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist