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General NPI Number Information
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NPI Number | 1205166527
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Entity Type | Individual
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Provider Name | HEATHER ANN BERGSTROM LAC
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Gender | Female
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Dates
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Enumeration Date | 01/08/2010
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Last Update Date | 07/11/2022
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Provider Practice Location Address
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Address Line | 9951 W ST LUKES DR
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City | NAMPA
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State | ID
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Zip | 83687-7914
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Country | US
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Telephone | 208-467-6700
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Fax |
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone |
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Fax | 888-361-5391
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | ACU-279
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License Number State | ID
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