Healthcare Provider Details

I. General information

NPI: 1124587761
Provider Name (Legal Business Name): ANCIENT WISDOM HEALING ARTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S SAINT FRANCIS DR STE C
SANTA FE NM
87505-4042
US

IV. Provider business mailing address

2 PERIWINKLE PL
SANTA FE NM
87508-1389
US

V. Phone/Fax

Practice location:
  • Phone: 505-210-2781
  • Fax:
Mailing address:
  • Phone: 505-210-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JACOB W WILCOX
Title or Position: OWNER/ACUPUNCTURIST
Credential: DOM
Phone: 505-210-2781