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General NPI Number Information
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NPI Number | 1265739841
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Entity Type | Organization
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Legal Business Name | NEW TRADITIONS TCM HERBS & CLINIC, LLC
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Dates
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Enumeration Date | 02/17/2011
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Last Update Date | 02/17/2011
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Provider Practice Location Address
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Address Line | 1925 JUAN TABO BLVD NE STE E
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-3359
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Country | US
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Telephone | 505-291-8017
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Fax |
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Provider Business Mailing Address
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Address Line | 1925 JUAN TABO BLVD NE STE E
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-3359
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Country | US
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Telephone | 505-291-8017
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | GARY ALLEN
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Credential | DOM
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Telephone | 505-291-8017
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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 | 350
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License Number State | NM
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