Healthcare Provider Details

I. General information

NPI: 1164471850
Provider Name (Legal Business Name): KELLY M MCCONVILLE M.S. TCM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23678 SAN VICENTE RD
RAMONA CA
92065-4245
US

IV. Provider business mailing address

13242 TRIUMPH DR
POWAY CA
92064-2980
US

V. Phone/Fax

Practice location:
  • Phone: 760-735-0983
  • Fax:
Mailing address:
  • Phone: 760-735-0983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 5534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: