Provider Demographics
NPI:1871055251
Name:KUBOTA, MARI (LAC)
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:KUBOTA
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 1:1321 WEBSTER ST APT D104
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3850
Mailing Address - Country:US
Mailing Address - Phone:828-301-0378
Mailing Address - Fax:
Practice Address - Street 1:2229 SANTA CLARA AVE STE B
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4409
Practice Address - Country:US
Practice Address - Phone:828-301-0378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13444171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist