Provider Demographics
NPI:1104154400
Name:WEBER, HOLLY (LAC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WEBER
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 1:4534 UTAH ST
Mailing Address - Street 2:APT 8
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3107
Mailing Address - Country:US
Mailing Address - Phone:619-807-9474
Mailing Address - Fax:
Practice Address - Street 1:3678 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4106
Practice Address - Country:US
Practice Address - Phone:619-807-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13146171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist