Healthcare Provider Details

I. General information

NPI: 1669832564
Provider Name (Legal Business Name): GOLDEN WEST ACUPUNCTURE AND WELLNESS LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9645
US

IV. Provider business mailing address

590 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9645
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-1570
  • Fax:
Mailing address:
  • Phone: 505-730-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1176
License Number StateNM

VIII. Authorized Official

Name: DR. STACIE R SHAIN
Title or Position: OWNER
Credential: DOM
Phone: 505-730-1570