Healthcare Provider Details

I. General information

NPI: 1750565495
Provider Name (Legal Business Name): WESTSIDE HERBS & ACUPUNCTURE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 MCMAHON BLVD NW STE 113
ALBUQUERQUE NM
87114-5412
US

IV. Provider business mailing address

6119 MUSTANG LN NW
ALBUQUERQUE NM
87120-2289
US

V. Phone/Fax

Practice location:
  • Phone: 505-890-9378
  • Fax:
Mailing address:
  • Phone: 505-890-9378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number869
License Number StateNM

VIII. Authorized Official

Name: BRIAN SCOTT CAREY
Title or Position: CFO
Credential: DOM
Phone: 505-890-9378