Healthcare Provider Details

I. General information

NPI: 1447707922
Provider Name (Legal Business Name): MARIE GUPTILL LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N WIGET LN STE 130
WALNUT CREEK CA
94598-2435
US

IV. Provider business mailing address

1250 NEWELL AVE #154
WALNUT CREEK CA
94596
US

V. Phone/Fax

Practice location:
  • Phone: 925-289-8431
  • Fax:
Mailing address:
  • Phone: 925-289-8431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 17010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: