Provider Demographics
NPI:1124329354
Name:ITO, CAROL (LAC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:ITO
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 1:578 SUTTON WAY
Mailing Address - Street 2:PMB 215
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-264-6685
Mailing Address - Fax:
Practice Address - Street 1:412 E. MAIN ST., STE. L
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-264-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2283171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist