Provider Demographics
NPI:1285094953
Name:BODYTECH ACUPUNCTURE
Entity type:Organization
Organization Name:BODYTECH ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KRISTAIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:910-200-8806
Mailing Address - Street 1:109 HINTON AVE
Mailing Address - Street 2:# 10
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4786
Mailing Address - Country:US
Mailing Address - Phone:910-200-8806
Mailing Address - Fax:
Practice Address - Street 1:109 HINTON AVE
Practice Address - Street 2:# 10
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4786
Practice Address - Country:US
Practice Address - Phone:910-200-8806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC317261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service