Provider Demographics
NPI:1720317548
Name:WISS, BETSY K (LAC)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:K
Last Name:WISS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:77 WINDY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-8085
Mailing Address - Country:US
Mailing Address - Phone:208-850-2752
Mailing Address - Fax:208-685-2767
Practice Address - Street 1:5909 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3039
Practice Address - Country:US
Practice Address - Phone:208-343-7700
Practice Address - Fax:208-685-2767
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID146171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist