Provider Demographics
NPI:1679796080
Name:WILLIAMS, ROBERT J (LAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-0361
Mailing Address - Country:US
Mailing Address - Phone:503-956-1747
Mailing Address - Fax:
Practice Address - Street 1:660 2ND AVE S
Practice Address - Street 2:SUITE 2A
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-6663
Practice Address - Country:US
Practice Address - Phone:503-956-1747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AC01066171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist