Healthcare Provider Details

I. General information

NPI: 1437984309
Provider Name (Legal Business Name): LEESA DIAN BOLDEN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1361
QUARTZSITE AZ
85346-1361
US

IV. Provider business mailing address

PO BOX 1361
QUARTZSITE AZ
85346-1361
US

V. Phone/Fax

Practice location:
  • Phone: 512-784-6929
  • Fax:
Mailing address:
  • Phone: 512-784-6929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberLAC-001125
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: