Healthcare Provider Details

I. General information

NPI: 1174953954
Provider Name (Legal Business Name): GEORGIA GOOD LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 CANARIOS CT. STE. 110
CHULA VISTA CA
91910
US

IV. Provider business mailing address

885 CANARIOS CT. STE. 110
CHULA VISTA CA
91910
US

V. Phone/Fax

Practice location:
  • Phone: 619-656-5102
  • Fax: 619-656-5143
Mailing address:
  • Phone: 619-656-5102
  • Fax: 619-656-5143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC15584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: