Provider Demographics
NPI:1184029662
Name:JADE DRAGON RED PHOENIX, LLC
Entity Type:Organization
Organization Name:JADE DRAGON RED PHOENIX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:ACA
Authorized Official - Phone:318-521-0701
Mailing Address - Street 1:158 DOWNS RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-6984
Mailing Address - Country:US
Mailing Address - Phone:318-521-0701
Mailing Address - Fax:
Practice Address - Street 1:2106 N 7TH ST
Practice Address - Street 2:#132
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4445
Practice Address - Country:US
Practice Address - Phone:318-521-0701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAACA.200053171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty