Provider Demographics
NPI:1891300216
Name:GAUTHIER, MICHAEL (DACM, LAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 WHEATSTONE ST SPC 181
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5444
Mailing Address - Country:US
Mailing Address - Phone:240-462-0501
Mailing Address - Fax:
Practice Address - Street 1:420 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4987
Practice Address - Country:US
Practice Address - Phone:619-501-7626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18661171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty