Provider Demographics
NPI:1992063259
Name:BOONE, THERESA (LAC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BOONE
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:PO BOX 16292
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92176-6292
Mailing Address - Country:US
Mailing Address - Phone:619-299-3778
Mailing Address - Fax:
Practice Address - Street 1:3737 MORAGA AVE
Practice Address - Street 2:SUITE A2
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5404
Practice Address - Country:US
Practice Address - Phone:619-299-3778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5506171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist