Provider Demographics
NPI:1891122958
Name:GRUER, TAHL (LAC)
Entity Type:Individual
Prefix:
First Name:TAHL
Middle Name:
Last Name:GRUER
Suffix:
Gender:M
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:PO BOX 99422
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92169-1422
Mailing Address - Country:US
Mailing Address - Phone:619-277-2375
Mailing Address - Fax:
Practice Address - Street 1:4000 RUFFIN RD
Practice Address - Street 2:C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1878
Practice Address - Country:US
Practice Address - Phone:619-277-2375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15452171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist