Provider Demographics
NPI:1558893453
Name:SOUL POTENTIAL ACUPUNCTURE AND WELLNESS, LLC
Entity Type:Organization
Organization Name:SOUL POTENTIAL ACUPUNCTURE AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-772-7588
Mailing Address - Street 1:300 E MILLER CT
Mailing Address - Street 2:# 445
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-8436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1189 S PERRY ST
Practice Address - Street 2:SUITE 150
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1959
Practice Address - Country:US
Practice Address - Phone:720-772-7588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002236171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty