Provider Demographics
NPI: | 1851588685 |
---|---|
Name: | FOUR WINDS ACUPUNCTURE |
Entity Type: | Organization |
Organization Name: | FOUR WINDS ACUPUNCTURE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DOCTOR ORIENTAL MEDICINE/OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | NATHAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | WALES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DOM |
Authorized Official - Phone: | 505-470-5705 |
Mailing Address - Street 1: | 1660 OLD PECOS TRL |
Mailing Address - Street 2: | SUITE H |
Mailing Address - City: | SANTA FE |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87505-4779 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-470-5705 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1660 OLD PECOS TRL |
Practice Address - Street 2: | SUITE H |
Practice Address - City: | SANTA FE |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87505-4779 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-470-5705 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-09-25 |
Last Update Date: | 2007-09-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NM | 926 | 171100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 171100000X | Other Service Providers | Acupuncturist | Group - Single Specialty |