Provider Demographics
NPI:1952452179
Name:JACKSONVILLE ORIENTAL MEDICINE CENTER
Entity Type:Organization
Organization Name:JACKSONVILLE ORIENTAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDUCA-MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:910-989-0002
Mailing Address - Street 1:99 VILLAGE DR
Mailing Address - Street 2:SUITE 16
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7067
Mailing Address - Country:US
Mailing Address - Phone:910-989-0002
Mailing Address - Fax:910-353-9753
Practice Address - Street 1:99 VILLAGE DR
Practice Address - Street 2:SUITE 16
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7067
Practice Address - Country:US
Practice Address - Phone:910-989-0002
Practice Address - Fax:910-353-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001915786171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty