Healthcare Provider Details

I. General information

NPI: 1952917536
Provider Name (Legal Business Name): REBECCA GREENWELL LAC, MACOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BEX GREENWELL LAC, MACOM

II. Dates (important events)

Enumeration Date: 09/19/2020
Last Update Date: 09/19/2020
Certification Date: 09/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9450 W FAIRVIEW AVE STE 120
BOISE ID
83704-8179
US

IV. Provider business mailing address

9450 W FAIRVIEW AVE STE 120
BOISE ID
83704-8179
US

V. Phone/Fax

Practice location:
  • Phone: 209-292-1374
  • Fax:
Mailing address:
  • Phone: 209-292-1374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACU380
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: