MEDICARE: CARL BRUCE STATER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1013085000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARL BRUCE STATER

Provider Business Mailing Address
First Line	:	474 W VERMONT AVE STE 104
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-6584
Country	:	US
Telephone Number	:	176-043-2988
Fax Number	:	176-043-2995

Provider Business Practice Location Address
First Line	:	474 W VERMONT AVE STE 104
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-6584
Country	:	US
Telephone Number	:	176-043-2988
Fax Number	:	176-043-2995

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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Directions to “ CARL BRUCE STATER ” Practice Location

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