Provider Demographics
NPI:1891128831
Name:LOCK-BOUVIER, CONNIE POND (LAC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:POND
Last Name:LOCK-BOUVIER
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 1:101 N EL CAMINO REAL
Mailing Address - Street 2:#4
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2700
Mailing Address - Country:US
Mailing Address - Phone:415-203-6025
Mailing Address - Fax:
Practice Address - Street 1:101 N EL CAMINO REAL
Practice Address - Street 2:#4
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2700
Practice Address - Country:US
Practice Address - Phone:415-203-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15288171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist