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General NPI Number Information
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NPI Number | 1417489519
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Entity Type | Organization
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Legal Business Name | BLACKHAWK ACUPUNCTURE AND HERBAL HEALING CENTER LLC
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 08/21/2020
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Provider Practice Location Address
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Address Line | 1307 FORTINO BLVD STE C
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City | PUEBLO
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State | CO
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Zip | 81008-2032
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Country | US
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Telephone | 719-582-1010
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Fax | 719-631-7012
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Provider Business Mailing Address
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Address Line | PO BOX 296
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City | BEULAH
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State | CO
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Zip | 81023-0296
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Country | US
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Telephone | 719-396-5375
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | TRACEY RENEE WALKER
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Credential |
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Telephone | 719-396-5375
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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 | ACU.0001916
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License Number State | CO
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