Healthcare Provider Details

I. General information

NPI: 1285820084
Provider Name (Legal Business Name): JEREMY JONATHAN RIESENFELD L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2007
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 CALLE DE SEBASTIAN UNIT D1
SANTA FE NM
87505-7321
US

IV. Provider business mailing address

1810 CALLE DE SEBASTIAN UNIT D1
SANTA FE NM
87505-7321
US

V. Phone/Fax

Practice location:
  • Phone: 202-843-0790
  • Fax:
Mailing address:
  • Phone: 202-843-0790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC500095
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: