Provider Demographics
NPI:1831635499
Name:MICHELLE RACINE LAC
Entity type:Organization
Organization Name:MICHELLE RACINE LAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RACINE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:603-502-4629
Mailing Address - Street 1:52 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3505
Mailing Address - Country:US
Mailing Address - Phone:603-502-4629
Mailing Address - Fax:
Practice Address - Street 1:24 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3851
Practice Address - Country:US
Practice Address - Phone:603-502-4629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA268874171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty