Provider Demographics
NPI:1679905293
Name:ARDENT LIVING ACUPUNCTURE INC.
Entity Type:Organization
Organization Name:ARDENT LIVING ACUPUNCTURE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOBIAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:DONAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CA
Authorized Official - Phone:217-622-4845
Mailing Address - Street 1:933 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1621
Mailing Address - Country:US
Mailing Address - Phone:217-622-4845
Mailing Address - Fax:
Practice Address - Street 1:4710 E BROADWAY STE 190
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-4105
Practice Address - Country:US
Practice Address - Phone:217-622-4845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI794-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty