Healthcare Provider Details

I. General information

NPI: 1265739841
Provider Name (Legal Business Name): NEW TRADITIONS TCM HERBS & CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 JUAN TABO BLVD NE STE E
ALBUQUERQUE NM
87112-3359
US

IV. Provider business mailing address

1925 JUAN TABO BLVD NE STE E
ALBUQUERQUE NM
87112-3359
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-8017
  • Fax:
Mailing address:
  • Phone: 505-291-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number350
License Number StateNM

VIII. Authorized Official

Name: GARY ALLEN
Title or Position: OWNER/MANAGER
Credential: DOM
Phone: 505-291-8017