Provider Demographics
NPI:1124587761
Name:ANCIENT WISDOM HEALING ARTS LLC
Entity Type:Organization
Organization Name:ANCIENT WISDOM HEALING ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-210-2781
Mailing Address - Street 1:2 PERIWINKLE PL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1389
Mailing Address - Country:US
Mailing Address - Phone:505-210-2781
Mailing Address - Fax:
Practice Address - Street 1:1301 S SAINT FRANCIS DR STE C
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4042
Practice Address - Country:US
Practice Address - Phone:505-210-2781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty