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General NPI Number Information
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NPI Number | 1154603108
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Entity Type | Organization
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Legal Business Name | RANDEL B. WING DOM PC
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Dates
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Enumeration Date | 09/15/2011
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Last Update Date | 09/15/2011
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Provider Practice Location Address
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Address Line | 2812 W COLORADO AVE STE 106
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City | COLORADO SPRINGS
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State | CO
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Zip | 80904-2470
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Country | US
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Telephone | 719-447-0046
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Fax | 719-447-4645
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Provider Business Mailing Address
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Address Line | 2812 W COLORADO AVE STE 106
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City | COLORADO SPRINGS
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State | CO
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Zip | 80904-2470
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Country | US
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Telephone | 719-447-0046
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Fax | 719-447-4645
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Authorized Official
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Title or Position | PRESIDENT
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Name | RANDEL BRUCE WING
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Credential | LAC, DOM, NMD
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Telephone | 719-447-0046
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 392
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License Number State | CO
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