Provider Demographics
NPI:1396411690
Name:EAGLE PEAK WELLNESS, INC.
Entity Type:Organization
Organization Name:EAGLE PEAK WELLNESS, INC.
Other - Org Name:EAGLE PEAK ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:RIDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LMT
Authorized Official - Phone:845-750-4896
Mailing Address - Street 1:394 HASBROUCK AVE # 2C
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4631
Mailing Address - Country:US
Mailing Address - Phone:845-750-4896
Mailing Address - Fax:
Practice Address - Street 1:394 HASBROUCK AVE # 2C
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4631
Practice Address - Country:US
Practice Address - Phone:845-750-4896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-18
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center