MEDICARE: HEIDI ANN BROCKMYRE L.AC.

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	171100000X	Acupuncturist	12558	CA

General Provider Information

NPI Number	:	1134378813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI ANN BROCKMYRE L.AC.

Provider Business Mailing Address
First Line	:	4870 SANTA MONICA AVE
Second Line	:	SUITE 2C
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-4802
Country	:	US
Telephone Number	:	619-518-6608
Fax Number	:

Provider Business Practice Location Address
First Line	:	4870 SANTA MONICA AVE
Second Line	:	SUITE 2C
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-4802
Country	:	US
Telephone Number	:	619-518-6608
Fax Number	:

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

Provider Enumeration Date	:	09/17/2008
Last Update Date	:	09/17/2008

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