Provider Demographics
NPI:1750695128
Name:SAN DIEGO ACUPUNCTURE AND NATURAL MEDICINE
Entity type:Organization
Organization Name:SAN DIEGO ACUPUNCTURE AND NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVANTERRA
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:619-887-0610
Mailing Address - Street 1:3636 4TH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3636 4TH AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4237
Practice Address - Country:US
Practice Address - Phone:619-501-5654
Practice Address - Fax:619-785-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8921171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ23467POtherBLUE SHIELD OF CALIFORNIA
CAZZZ55242YOtherBLUE SHIELD OF CALIFORNIA