Provider Demographics
NPI:1073094280
Name:GRACE ACUPUNCTURE HERBAL MEDICINE
Entity Type:Organization
Organization Name:GRACE ACUPUNCTURE HERBAL MEDICINE
Other - Org Name:GRACE ACUPUNCTURE HERBAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:MATIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DACM, LOM
Authorized Official - Phone:323-578-6950
Mailing Address - Street 1:65 E ELIZABETH AVE APT PH1004
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-6518
Mailing Address - Country:US
Mailing Address - Phone:323-578-6950
Mailing Address - Fax:
Practice Address - Street 1:406 DELAWARE AVE STE 4
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1472
Practice Address - Country:US
Practice Address - Phone:619-483-1985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-25
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000243171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty