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General NPI Number Information
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NPI Number | 1508282138
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Entity Type | Individual
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Provider Name | DIANNE GRACE MALLIK L.AC.
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Gender | Female
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Dates
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Enumeration Date | 03/06/2014
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Last Update Date | 05/26/2020
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Provider Practice Location Address
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Address Line | 2330 MAIN ST STE D
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City | RAMONA
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State | CA
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Zip | 92065-2539
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Country | US
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Telephone | 858-208-8250
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Fax |
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Provider Business Mailing Address
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Address Line | 17218 BOCA RATON LN
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City | POWAY
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State | CA
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Zip | 92064-1304
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Country | US
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Telephone | 802-734-3838
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 091.0000161
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License Number State | VT
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC3885
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License Number State | CA
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