Provider Demographics
NPI:1669832564
Name:GOLDEN WEST ACUPUNCTURE AND WELLNESS LLC.
Entity Type:Organization
Organization Name:GOLDEN WEST ACUPUNCTURE AND WELLNESS LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-730-1570
Mailing Address - Street 1:590 BOSQUE FARMS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9645
Mailing Address - Country:US
Mailing Address - Phone:505-730-1570
Mailing Address - Fax:
Practice Address - Street 1:590 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9645
Practice Address - Country:US
Practice Address - Phone:505-730-1570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty