Provider Demographics
NPI:1588181101
Name:LAKE TAHOE ACUPUNCTURE AND WELLNESS
Entity Type:Organization
Organization Name:LAKE TAHOE ACUPUNCTURE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNEKEN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:530-494-0900
Mailing Address - Street 1:2244 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3408
Mailing Address - Country:US
Mailing Address - Phone:530-494-0900
Mailing Address - Fax:530-494-0902
Practice Address - Street 1:2244 BARTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3408
Practice Address - Country:US
Practice Address - Phone:530-494-0900
Practice Address - Fax:530-494-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13270171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty