Provider Demographics
NPI:1770813412
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
Authorized Official - Prefix:
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DIVANTERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
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:619-887-0610
Mailing Address - Fax:619-785-3387
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:2009-12-31
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA115175F00000X
CA8921171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073666186OtherNPI
CA1750695128OtherNPI