Provider Demographics
NPI:1942477336
Name:ORIGINAL MEDICINE CENTER FOR HEALING
Entity Type:Organization
Organization Name:ORIGINAL MEDICINE CENTER FOR HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBA
Authorized Official - Middle Name:I
Authorized Official - Last Name:EAGLES
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-604-3434
Mailing Address - Street 1:610 11TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1808
Mailing Address - Country:US
Mailing Address - Phone:505-604-3434
Mailing Address - Fax:505-242-2410
Practice Address - Street 1:119 SAN PASQUALE AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1153
Practice Address - Country:US
Practice Address - Phone:505-604-3434
Practice Address - Fax:505-242-2410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM833171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty