Healthcare Provider Details

I. General information

NPI: 1053482729
Provider Name (Legal Business Name): BETHANY RICHARDSON L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 GARDENDALE ST STE B103
SAN ANTONIO TX
78229-3182
US

IV. Provider business mailing address

4207 GARDENDALE ST STE B103
SAN ANTONIO TX
78229-3182
US

V. Phone/Fax

Practice location:
  • Phone: 210-999-5579
  • Fax:
Mailing address:
  • Phone: 210-999-5579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC8377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: