Provider Demographics
NPI:1063846574
Name:LM AT BLUEGREEN
Entity Type:Organization
Organization Name:LM AT BLUEGREEN
Other - Org Name:BLUEGREEN ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONORA
Authorized Official - Middle Name:GEVAERD
Authorized Official - Last Name:MANEKIN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MAC
Authorized Official - Phone:443-388-1110
Mailing Address - Street 1:301 W 29TH ST
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2910
Mailing Address - Country:US
Mailing Address - Phone:443-388-1110
Mailing Address - Fax:
Practice Address - Street 1:301 W 29TH ST
Practice Address - Street 2:SUITE 2001
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2910
Practice Address - Country:US
Practice Address - Phone:443-388-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01822171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty