Provider Demographics
NPI:1992103808
Name:MONTALVO-AGUILERA, REGINA VICTORIA (LAC)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:VICTORIA
Last Name:MONTALVO-AGUILERA
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 1958
Mailing Address - Street 2:
Mailing Address - City:JULIAN
Mailing Address - State:CA
Mailing Address - Zip Code:92036-1958
Mailing Address - Country:US
Mailing Address - Phone:760-445-3035
Mailing Address - Fax:
Practice Address - Street 1:2130 WYNOLA ROAD
Practice Address - Street 2:
Practice Address - City:JULIAN
Practice Address - State:CA
Practice Address - Zip Code:92036-1958
Practice Address - Country:US
Practice Address - Phone:760-445-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 8787171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist