Provider Demographics
NPI:1083938831
Name:FRACTAL DRAGON MEDICINE & ORIENTAL MEDICINE, LLC
Entity Type:Organization
Organization Name:FRACTAL DRAGON MEDICINE & ORIENTAL MEDICINE, LLC
Other - Org Name:FRACTAL DRAGON MEDICINE, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:PERLEE
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:DIPL OM
Authorized Official - Phone:720-261-1680
Mailing Address - Street 1:9527 HURTY AVE
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-9123
Mailing Address - Country:US
Mailing Address - Phone:720-261-1680
Mailing Address - Fax:
Practice Address - Street 1:8370 W COAL MINE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-4401
Practice Address - Country:US
Practice Address - Phone:303-979-0342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO858171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty