Provider Demographics
NPI:1487164323
Name:DEL REAL, JOSE A (LAC)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:DEL REAL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:641 E SAN YSIDRO BLVD # B3-525
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3129
Mailing Address - Country:US
Mailing Address - Phone:619-253-3105
Mailing Address - Fax:
Practice Address - Street 1:1229 3RD AVE STE C
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3212
Practice Address - Country:US
Practice Address - Phone:619-271-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17795171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist