Provider Demographics
NPI:1487010526
Name:DRAGON WELL ACUPUNCTURE AND HERBAL MEDICINE, LLC
Entity Type:Organization
Organization Name:DRAGON WELL ACUPUNCTURE AND HERBAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/ ACUPUNCTURIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEDORA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MAOM
Authorized Official - Phone:860-420-8855
Mailing Address - Street 1:208 POLE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281-1202
Mailing Address - Country:US
Mailing Address - Phone:860-420-8855
Mailing Address - Fax:
Practice Address - Street 1:36 CHURCH ST
Practice Address - Street 2:36A
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1866
Practice Address - Country:US
Practice Address - Phone:860-481-3770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT594171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty