Provider Demographics
NPI:1780218297
Name:SIMON, BREANNE H (L AC DACM)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:H
Last Name:SIMON
Suffix:
Gender:F
Credentials:L AC DACM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N COAST HIGHWAY 101
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2529
Mailing Address - Country:US
Mailing Address - Phone:760-705-4432
Mailing Address - Fax:
Practice Address - Street 1:412 N COAST HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2529
Practice Address - Country:US
Practice Address - Phone:760-705-4432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18820171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist