Healthcare Provider Details

I. General information

NPI: 1942800826
Provider Name (Legal Business Name): ANCIENT HEALING WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N PARK BLVD
SAN ANTONIO TX
78204-2430
US

IV. Provider business mailing address

103 N PARK BLVD
SAN ANTONIO TX
78204-2430
US

V. Phone/Fax

Practice location:
  • Phone: 210-663-4643
  • Fax: 210-874-6617
Mailing address:
  • Phone: 210-663-4643
  • Fax: 210-874-6617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARIA J GOMEZ-MEDINA
Title or Position: OWNER
Credential: MSOM, PH.D
Phone: 210-663-4643