Provider Demographics
NPI:1245428721
Name:FOUR CORNERS ORIENTAL MEDICINE AND ACUPUNCTURE, LLC
Entity Type:Organization
Organization Name:FOUR CORNERS ORIENTAL MEDICINE AND ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:RHENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-564-3242
Mailing Address - Street 1:2130 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2123
Mailing Address - Country:US
Mailing Address - Phone:505-564-3242
Mailing Address - Fax:
Practice Address - Street 1:2130 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2123
Practice Address - Country:US
Practice Address - Phone:505-564-3242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNMBAOM662171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty