Provider Demographics
NPI:1255536272
Name:GRAY, BOBETTE RUTH (LAC)
Entity type:Individual
Prefix:
First Name:BOBETTE
Middle Name:RUTH
Last Name:GRAY
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 1:1036 E. YAQUINA BAY DR.
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-989-7008
Mailing Address - Fax:208-376-4778
Practice Address - Street 1:1036 E. YAQUINA BAY DRIVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-989-7008
Practice Address - Fax:208-376-4778
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-122171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNCBL1Medicare UPIN
ID000010150867Medicare UPIN