Provider Demographics
NPI:1114318094
Name:ANCIENT WIDOM HEALING ARTS
Entity Type:Organization
Organization Name:ANCIENT WIDOM HEALING ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:L AC, MTOM
Authorized Official - Phone:443-838-3141
Mailing Address - Street 1:918 WELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1921
Mailing Address - Country:US
Mailing Address - Phone:443-838-3141
Mailing Address - Fax:410-377-6168
Practice Address - Street 1:658 KENILWORTH DR
Practice Address - Street 2:SUITE #102
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2312
Practice Address - Country:US
Practice Address - Phone:443-838-3141
Practice Address - Fax:410-377-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLIC # U01120171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty