Provider Demographics
NPI:1447356613
Name:STEWART, ROBERT BRUCE (LAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
Last Name:STEWART
Suffix:
Gender:M
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:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91933-0762
Mailing Address - Country:US
Mailing Address - Phone:619-392-0937
Mailing Address - Fax:619-565-2288
Practice Address - Street 1:600 PALM AVE STE 112
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1245
Practice Address - Country:US
Practice Address - Phone:619-392-0937
Practice Address - Fax:619-565-2288
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 6392171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist