Provider Demographics
NPI:1609045459
Name:EAGLE RIVER ACUPUNCTURE LLC.
Entity Type:Organization
Organization Name:EAGLE RIVER ACUPUNCTURE LLC.
Other - Org Name:EAGLE RIVER ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEIF
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIDIN-LAMON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:907-726-5200
Mailing Address - Street 1:11723 OLD GLENN HWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7733
Mailing Address - Country:US
Mailing Address - Phone:907-726-5200
Mailing Address - Fax:
Practice Address - Street 1:11723 OLD GLENN HWY
Practice Address - Street 2:SUITE 205
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7733
Practice Address - Country:US
Practice Address - Phone:907-726-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKA112171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty