Healthcare Provider Details

I. General information

NPI: 1194157834
Provider Name (Legal Business Name): CAROLYN O'CONNELL MAYO MS, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4153 PIEDMONT AVE APT 1
OAKLAND CA
94611-5108
US

IV. Provider business mailing address

4153 PIEDMONT AVE APT 1
OAKLAND CA
94611-5108
US

V. Phone/Fax

Practice location:
  • Phone: 510-333-0695
  • Fax: 510-291-2286
Mailing address:
  • Phone: 510-817-4538
  • Fax: 510-291-2286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: