Provider Demographics
NPI:1174979546
Name:RODERICK, HEATHER (LAC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RODERICK
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 1:5075 W POINT LOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1312
Mailing Address - Country:US
Mailing Address - Phone:702-592-4019
Mailing Address - Fax:
Practice Address - Street 1:3666 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5201
Practice Address - Country:US
Practice Address - Phone:702-592-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17074171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist