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General NPI Number Information
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NPI Number | 1306199864
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Entity Type | Organization
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Legal Business Name | FORMLESS FORM QIGONG & ACUPUNCTURE
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Dates
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Enumeration Date | 10/22/2012
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Last Update Date | 03/01/2018
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Provider Practice Location Address
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Address Line | 5603 CHICAGO AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55417-2429
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Country | US
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Telephone | 612-708-0753
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Fax |
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Provider Business Mailing Address
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Address Line | 5603 CHICAGO AVE
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City | MINNEAPOLIS
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State | MN
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Zip | 55417-2429
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Country | US
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Telephone | 612-708-0753
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PENG RODEN HER
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Credential | LAC
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Telephone | 612-708-0753
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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 | 1588
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License Number State | MN
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