Healthcare Provider Details

I. General information

NPI: 1871662593
Provider Name (Legal Business Name): ALISSA MARJORIE STOCKTON L.AC., D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. ALISSA MARJORIE POLEN

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 N. COLLEGE AVE.
THATCHER AZ
85552
US

IV. Provider business mailing address

1059 N. COLLEGE AVE. PO BOX 1119
THATCHER AZ
85552
US

V. Phone/Fax

Practice location:
  • Phone: 928-965-9545
  • Fax:
Mailing address:
  • Phone: 928-965-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0373
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAZ0373
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: