Provider Demographics
NPI:1043845159
Name:BOTTARO, LILLIAM (LAC)
Entity Type:Individual
Prefix:
First Name:LILLIAM
Middle Name:
Last Name:BOTTARO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:LILLIAM
Other - Middle Name:BOTTARO
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11621 SW 82ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11621 SW 82ND TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3628
Practice Address - Country:US
Practice Address - Phone:786-262-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4134171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty