Healthcare Provider Details

I. General information

NPI: 1043753601
Provider Name (Legal Business Name): LAINE GALLEGOS ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 PENROSE PL SUITE 202
BOULDER CO
80301-1818
US

IV. Provider business mailing address

702 DOUNCE ST
LAFAYETTE CO
80026-2504
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-3034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0002234
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. LAINE GALLEGOS
Title or Position: ACUPUNCTURIST
Credential: L.AC.
Phone: 970-948-6229