Provider Demographics
NPI:1265971089
Name:TEN BROECK, KRISTIN (LAC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:TEN BROECK
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 1:109 BRADY CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4554
Mailing Address - Country:US
Mailing Address - Phone:919-230-2456
Mailing Address - Fax:919-594-6254
Practice Address - Street 1:109 BRADY CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4554
Practice Address - Country:US
Practice Address - Phone:919-230-2456
Practice Address - Fax:919-594-6254
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC861171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist