Provider Demographics
NPI:1710454053
Name:FERNANDEZ, RAYNE ALMAZAN (MSTOM, LAC)
Entity Type:Individual
Prefix:MRS
First Name:RAYNE
Middle Name:ALMAZAN
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1694 GUSTAVO ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-3409
Mailing Address - Country:US
Mailing Address - Phone:619-981-9466
Mailing Address - Fax:
Practice Address - Street 1:7777 ALVARADO RD STE 287
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-8216
Practice Address - Country:US
Practice Address - Phone:619-981-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18228171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
99469842FOtherMEDI-CAL
NCF738A76008OtherANTHEM BLUE CROSS