Healthcare Provider Details

I. General information

NPI: 1063165843
Provider Name (Legal Business Name): EARTH ELEMENTS ACUPUNCTURE & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 N 1ST AVE E
ELY MN
55731-1203
US

IV. Provider business mailing address

1133 E WASHINGTON ST
ELY MN
55731-1707
US

V. Phone/Fax

Practice location:
  • Phone: 612-207-3660
  • Fax: 218-242-8409
Mailing address:
  • Phone: 612-207-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SARA FETYKO
Title or Position: OWNER
Credential: LAC
Phone: 612-207-3660