Healthcare Provider Details

I. General information

NPI: 1457700213
Provider Name (Legal Business Name): ROBERT WILEY DUBOIS LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2016
Last Update Date: 06/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 ASHBY AVE
BERKELEY CA
94705-2200
US

IV. Provider business mailing address

3300 KINGSLAND AVE
OAKLAND CA
94619-2603
US

V. Phone/Fax

Practice location:
  • Phone: 603-534-3251
  • Fax:
Mailing address:
  • Phone: 603-534-3251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number16909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: