Provider Demographics
NPI:1215113725
Name:MORALES, MARY LYNN (LAC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNN
Last Name:MORALES
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 1:1500 OAK VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1425
Mailing Address - Country:US
Mailing Address - Phone:510-326-7928
Mailing Address - Fax:
Practice Address - Street 1:1500 OAK VIEW AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94706-1425
Practice Address - Country:US
Practice Address - Phone:510-326-7928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7295171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist