MEDICARE: WENDY E WEISS LIC. AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	4208	CA

General Provider Information

NPI Number	:	1013071836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY E WEISS LIC. AC.

Provider Business Mailing Address
First Line	:	PO BOX 105
Second Line	:
City	:	LOWER LAKE
State	:	CA
Zip	:	95457-0105
Country	:	US
Telephone Number	:	707-277-0891
Fax Number	:	707-277-0891

Provider Business Practice Location Address
First Line	:	9667 HWY 29
Second Line	:	SUITE 202
City	:	LOWER LAKE
State	:	CA
Zip	:	95457-4804
Country	:	US
Telephone Number	:	707-277-0891
Fax Number	:	707-277-0891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	06/03/2020

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