Provider Demographics
NPI:1134378813
Name:BROCKMYRE, HEIDI ANN (LAC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:ANN
Last Name:BROCKMYRE
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 1:4870 SANTA MONICA AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-4802
Mailing Address - Country:US
Mailing Address - Phone:619-518-6608
Mailing Address - Fax:
Practice Address - Street 1:4870 SANTA MONICA AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-4802
Practice Address - Country:US
Practice Address - Phone:619-518-6608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12558171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist