Healthcare Provider Details

I. General information

NPI: 1083949358
Provider Name (Legal Business Name): MILLENNIUM WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 N GRAND MESA DR
CEDAREDGE CO
81413-8388
US

IV. Provider business mailing address

190 N GRAND MESA DR
CEDAREDGE CO
81413-8388
US

V. Phone/Fax

Practice location:
  • Phone: 970-856-4729
  • Fax: 970-856-4734
Mailing address:
  • Phone: 970-856-4729
  • Fax: 970-856-4734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1293
License Number StateCO

VIII. Authorized Official

Name: KRISTIE M. LAVALLEY
Title or Position: ACUPUNCTURIST
Credential: L.AC.
Phone: 970-856-4729