Provider Demographics
NPI:1891929246
Name:CLOETE, IZELLE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:IZELLE
Middle Name:
Last Name:CLOETE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MRS
Other - First Name:IZELLE
Other - Middle Name:
Other - Last Name:COETZEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 33390
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163
Mailing Address - Country:US
Mailing Address - Phone:619-550-8175
Mailing Address - Fax:
Practice Address - Street 1:3555 KENYON STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-550-8175
Practice Address - Fax:619-358-9629
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12875171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist