Provider Demographics
NPI:1710317227
Name:LIFECYCLE ACUPUNCTURE
Entity Type:Organization
Organization Name:LIFECYCLE ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DONNA
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:303-656-0048
Mailing Address - Street 1:925 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2141
Mailing Address - Country:US
Mailing Address - Phone:303-656-0048
Mailing Address - Fax:
Practice Address - Street 1:925 37TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2141
Practice Address - Country:US
Practice Address - Phone:303-656-0048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1761302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12471245OtherCAQH #