Provider Demographics
NPI:1255732533
Name:DEVORE, CARMEN (LAC)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:DEVORE
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 1:4774 E MALTA ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3815
Mailing Address - Country:US
Mailing Address - Phone:562-505-0280
Mailing Address - Fax:
Practice Address - Street 1:4774 E MALTA ST
Practice Address - Street 2:UNIT 2
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3815
Practice Address - Country:US
Practice Address - Phone:562-505-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14268171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist