Healthcare Provider Details

I. General information

NPI: 1194559955
Provider Name (Legal Business Name): GRACE REEGO DACM, L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 LA JOLLA VILLAGE DR
LA JOLLA CA
92037-1402
US

IV. Provider business mailing address

4180 LA JOLLA VILLAGE DR
LA JOLLA CA
92037-1402
US

V. Phone/Fax

Practice location:
  • Phone: 866-277-2659
  • Fax:
Mailing address:
  • Phone: 866-277-2659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number6786
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: