Healthcare Provider Details

I. General information

NPI: 1174868558
Provider Name (Legal Business Name): WOVEN WISDOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3729 W 32ND AVE
DENVER CO
80211-3121
US

IV. Provider business mailing address

3628 MARIPOSA ST
DENVER CO
80211-3041
US

V. Phone/Fax

Practice location:
  • Phone: 720-440-2281
  • Fax:
Mailing address:
  • Phone: 720-440-2281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACU.0001815
License Number StateCO

VIII. Authorized Official

Name: AMY LU BOOM
Title or Position: LICENSED ACUPUNCTURIST
Credential: L.AC., DIPLOM
Phone: 720-440-2281