Provider Demographics
NPI:1154936623
Name:BRECKE, MAGALI S (LAC)
Entity type:Individual
Prefix:
First Name:MAGALI
Middle Name:S
Last Name:BRECKE
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 1:1040 MYSTERY SPOT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-9660
Mailing Address - Country:US
Mailing Address - Phone:619-569-7908
Mailing Address - Fax:
Practice Address - Street 1:1040 MYSTERY SPOT RD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-9660
Practice Address - Country:US
Practice Address - Phone:619-569-7908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16670171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist