Basic Information
| Provider Information | |||||||||
| NPI: | 1477867828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRYOR | ||||||||
| FirstName: | CARLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6221 METROPOLITAN ST | ||||||||
| Address2: | UNIT 101 | ||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920093096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607075080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3809 PLAZA DR | ||||||||
| Address2: | STE 112 | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920564625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609412630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT36873 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PT36873 | 01 | CA | PT LICENSE | OTHER |