Healthcare Provider Details

I. General information

NPI: 1720109101
Provider Name (Legal Business Name): ACUPUNCTURE CENTER OF LOS ALAMOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 TRINITY DR SUITE 14
LOS ALAMOS NM
87544-2376
US

IV. Provider business mailing address

2610 TRINITY DR SUITE 14
LOS ALAMOS NM
87544-2376
US

V. Phone/Fax

Practice location:
  • Phone: 505-663-1339
  • Fax: 505-662-7371
Mailing address:
  • Phone: 505-663-1339
  • Fax: 505-662-7371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number534
License Number StateNM

VIII. Authorized Official

Name: ANDREA JOHANSEN
Title or Position: PRESIDENT
Credential: DOM
Phone: 505-663-1339