Provider Demographics
NPI:1306199864
Name:FORMLESS FORM QIGONG & ACUPUNCTURE
Entity Type:Organization
Organization Name:FORMLESS FORM QIGONG & ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PENG
Authorized Official - Middle Name:RODEN
Authorized Official - Last Name:HER
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:612-708-0753
Mailing Address - Street 1:5603 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2429
Mailing Address - Country:US
Mailing Address - Phone:612-708-0753
Mailing Address - Fax:
Practice Address - Street 1:5603 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2429
Practice Address - Country:US
Practice Address - Phone:612-708-0753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1588171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty