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General NPI Number Information
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NPI Number | 1326443359
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Entity Type | Organization
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Legal Business Name | WANDERING SAGE MEDICINE LLC
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Dates
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Enumeration Date | 11/04/2014
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 1371 HECLA DR SUITE E
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City | LOUISVILLE
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State | CO
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Zip | 80027-2327
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Country | US
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Telephone | 303-530-0488
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 18838
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City | BOULDER
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State | CO
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Zip | 80308-1838
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRACIE E DISSINGER
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Credential | DP.OM
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Telephone | 303-530-0488
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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 | ACU1624
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License Number State | CO
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