Provider Demographics
NPI:1629811781
Name:ANCIENT ROOTS ACUPUNCTURE PLLC
Entity type:Organization
Organization Name:ANCIENT ROOTS ACUPUNCTURE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:815-693-0810
Mailing Address - Street 1:10850 W LARAWAY RD STE 3W
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-6400
Mailing Address - Country:US
Mailing Address - Phone:815-693-0810
Mailing Address - Fax:
Practice Address - Street 1:10850 W LARAWAY RD STE 3W
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-6400
Practice Address - Country:US
Practice Address - Phone:815-693-0810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty