Provider Demographics
NPI:1942026976
Name:VINCENT, MARY (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2712 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-2738
Mailing Address - Country:US
Mailing Address - Phone:619-306-3735
Mailing Address - Fax:
Practice Address - Street 1:1149 N 2ND ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5024
Practice Address - Country:US
Practice Address - Phone:619-440-2440
Practice Address - Fax:619-440-9440
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA13096171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist