Healthcare Provider Details

I. General information

NPI: 1164666236
Provider Name (Legal Business Name): BETSY CUSTARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3484 N CONSTANCE DR.
PRESCOTT VALLEY AZ
86314
US

IV. Provider business mailing address

440 N WASHINGTON AVE
PRESCOTT AZ
86301-2642
US

V. Phone/Fax

Practice location:
  • Phone: 928-443-1991
  • Fax:
Mailing address:
  • Phone: 928-443-1991
  • Fax: 928-771-2351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number12586
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: