Provider Demographics
NPI:1043753601
Name:LAINE GALLEGOS ACUPUNCTURE
Entity Type:Organization
Organization Name:LAINE GALLEGOS ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:970-948-6229
Mailing Address - Street 1:702 DOUNCE ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3405 PENROSE PL
Practice Address - Street 2:SUITE 202
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1818
Practice Address - Country:US
Practice Address - Phone:303-443-3034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002234171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty