Provider Demographics
NPI:1447497151
Name:IDIOKITAS, RISI MARIE (LAC)
Entity type:Individual
Prefix:MRS
First Name:RISI
Middle Name:MARIE
Last Name:IDIOKITAS
Suffix:
Gender:F
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 305
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20868-0305
Mailing Address - Country:US
Mailing Address - Phone:240-486-4295
Mailing Address - Fax:
Practice Address - Street 1:2140 SPENCERVILLE RD
Practice Address - Street 2:
Practice Address - City:SPENCERVILLE
Practice Address - State:MD
Practice Address - Zip Code:20868-3009
Practice Address - Country:US
Practice Address - Phone:240-486-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01700171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist