Provider Demographics
NPI:1942411814
Name:MCINTYRE, CARMEN MELANIE (LAC)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:MELANIE
Last Name:MCINTYRE
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 1:3400 KENILWORTH LN
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1662
Mailing Address - Country:US
Mailing Address - Phone:831-359-6286
Mailing Address - Fax:
Practice Address - Street 1:526 SOQUEL AVE
Practice Address - Street 2:STE. D
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2321
Practice Address - Country:US
Practice Address - Phone:831-359-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8728171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0087280OtherMEDICAL