Provider Demographics
NPI:1902966849
Name:RIDER, CAROL (LAC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RIDER
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 1:6046 CORNERSTONE CT W
Mailing Address - Street 2:STE. 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4758
Mailing Address - Country:US
Mailing Address - Phone:858-453-2048
Mailing Address - Fax:
Practice Address - Street 1:6046 CORNERSTONE CT W
Practice Address - Street 2:STE. 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4758
Practice Address - Country:US
Practice Address - Phone:858-453-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5937171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC5937OtherLICENSE NUMBER