Provider Demographics
NPI:1043492762
Name:WALTERS, RICHELE LEIGH (LAC)
Entity type:Individual
Prefix:
First Name:RICHELE
Middle Name:LEIGH
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 MOORE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3017
Mailing Address - Country:US
Mailing Address - Phone:619-723-3559
Mailing Address - Fax:
Practice Address - Street 1:2356 MOORE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3017
Practice Address - Country:US
Practice Address - Phone:619-723-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12067171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist