Provider Demographics
NPI:1992416044
Name:BURGOS DIAZ, BETSY ENID (CHIRCH61363606)
Entity type:Individual
Prefix:DR
First Name:BETSY
Middle Name:ENID
Last Name:BURGOS DIAZ
Suffix:
Gender:F
Credentials:CHIRCH61363606
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 VISTA LOOP SW APT 32-102
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-0472
Mailing Address - Country:US
Mailing Address - Phone:507-589-5406
Mailing Address - Fax:
Practice Address - Street 1:204 PINEHURST DR SW STE 103
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4500
Practice Address - Country:US
Practice Address - Phone:360-352-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.61363606111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor