Provider Demographics
NPI:1700523040
Name:ANCIENT ROOTS ACUPUNCTURE AND HERBAL MEDICINE
Entity Type:Organization
Organization Name:ANCIENT ROOTS ACUPUNCTURE AND HERBAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:603-557-5237
Mailing Address - Street 1:20 BLACKSTONE BLVD APT 14
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5448
Mailing Address - Country:US
Mailing Address - Phone:603-557-5237
Mailing Address - Fax:
Practice Address - Street 1:20 BLACKSTONE BLVD APT 14
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5448
Practice Address - Country:US
Practice Address - Phone:603-557-5237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty