Healthcare Provider Details

I. General information

NPI: 1689979593
Provider Name (Legal Business Name): DAMIANA CORCA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 IRIS AVE SUITE 250B
BOULDER CO
80301
US

IV. Provider business mailing address

3825 IRIS AVE SUITE 250B
BOULDER CO
80301
US

V. Phone/Fax

Practice location:
  • Phone: 303-440-1033
  • Fax:
Mailing address:
  • Phone: 303-440-1033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number168
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAW1694
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: