Provider Demographics
NPI:1750747028
Name:MODERN ANCIENTS DBA VERDE VALLEY ACUPUNCTURE
Entity type:Organization
Organization Name:MODERN ANCIENTS DBA VERDE VALLEY ACUPUNCTURE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,MEMBER,PRACTICIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:928-639-3700
Mailing Address - Street 1:719 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3708
Mailing Address - Country:US
Mailing Address - Phone:928-639-3700
Mailing Address - Fax:928-304-7171
Practice Address - Street 1:719 N 5TH ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3708
Practice Address - Country:US
Practice Address - Phone:928-639-3700
Practice Address - Fax:928-304-7171
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN ANCIENTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-02
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0515171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty