Provider Demographics
NPI:1215294244
Name:STARK, ERICA DAWN (LAC)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:DAWN
Last Name:STARK
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 1:5338 CAMINO PLAYA NORTE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-4114
Mailing Address - Country:US
Mailing Address - Phone:858-568-2189
Mailing Address - Fax:
Practice Address - Street 1:5222 BALBOA AVE
Practice Address - Street 2:SUITE 43
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6904
Practice Address - Country:US
Practice Address - Phone:858-568-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 14659171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist