MEDICARE: GEORGE JACOB ROSENBAUM DIPL. AC., LAC.

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	ACU-408	ID

General Provider Information

NPI Number	:	1205429693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE JACOB ROSENBAUM DIPL. AC., LAC.

Provider Business Mailing Address
First Line	:	1656 S LOGGERS POND PL APT 22
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-7509
Country	:	US
Telephone Number	:	540-878-6041
Fax Number	:

Provider Business Practice Location Address
First Line	:	10074 W FAIRVIEW AVE STE 150
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-5002
Country	:	US
Telephone Number	:	540-878-6041
Fax Number	:

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

Provider Enumeration Date	:	02/16/2021
Last Update Date	:	02/16/2021

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