Healthcare Provider Details

I. General information

NPI: 1962820456
Provider Name (Legal Business Name): FULL WELL ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 COLUMBIA ST
SANTA FE NM
87505-3965
US

IV. Provider business mailing address

838 COLUMBIA ST
SANTA FE NM
87505-3965
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-8048
  • Fax:
Mailing address:
  • Phone: 505-690-8048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1072
License Number StateNM

VIII. Authorized Official

Name: DR. PAMELA GREGG FLAX
Title or Position: OWNER
Credential: DOM
Phone: 505-690-8048