Provider Demographics
NPI:1457964280
Name:JADE LOTUS ACUPUNCTURE AND ORIENTAL MEDICINE
Entity Type:Organization
Organization Name:JADE LOTUS ACUPUNCTURE AND ORIENTAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:AP, LMT
Authorized Official - Phone:850-368-7872
Mailing Address - Street 1:1541 SCENIC GULF DR UNIT 5
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-6953
Mailing Address - Country:US
Mailing Address - Phone:850-368-1685
Mailing Address - Fax:
Practice Address - Street 1:12273 US HIGHWAY 98 W STE 120
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-6945
Practice Address - Country:US
Practice Address - Phone:850-368-1685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty