Provider Demographics
NPI:1336746890
Name:URTIAGA, KELLY (LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:URTIAGA
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 1:302 LA GARDE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-5305
Mailing Address - Country:US
Mailing Address - Phone:210-275-0451
Mailing Address - Fax:
Practice Address - Street 1:7870 BROADWAY BLDG A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2583
Practice Address - Country:US
Practice Address - Phone:210-236-5862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01970171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty