Healthcare Provider Details

I. General information

NPI: 1366108193
Provider Name (Legal Business Name): GENTLE TIDES ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 PENROSE PL STE 206
BOULDER CO
80301-1820
US

IV. Provider business mailing address

2859 SHADOW CREEK DR APT 106
BOULDER CO
80303-1755
US

V. Phone/Fax

Practice location:
  • Phone: 303-618-0390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ROSEMARY RAST
Title or Position: OWNER
Credential:
Phone: 303-618-0390