Healthcare Provider Details

I. General information

NPI: 1447356613
Provider Name (Legal Business Name): ROBERT BRUCE STEWART L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PALM AVE STE 112
IMPERIAL BEACH CA
91932-1245
US

IV. Provider business mailing address

PO BOX 762
IMPERIAL BEACH CA
91933-0762
US

V. Phone/Fax

Practice location:
  • Phone: 619-392-0937
  • Fax: 619-565-2288
Mailing address:
  • Phone: 619-392-0937
  • Fax: 619-565-2288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 6392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: