Healthcare Provider Details

I. General information

NPI: 1003193384
Provider Name (Legal Business Name): KRISTEN MARY BRUMLEVE MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 GRAND AVE STE 208
CARLSBAD CA
92008-2371
US

IV. Provider business mailing address

8875 COSTA VERDE BLVD APT 414
SAN DIEGO CA
92122-6655
US

V. Phone/Fax

Practice location:
  • Phone: 760-730-9675
  • Fax: 760-295-8623
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT11472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: