Provider Demographics
NPI:1417489519
Name:BLACKHAWK ACUPUNCTURE AND HERBAL HEALING CENTER LLC
Entity type:Organization
Organization Name:BLACKHAWK ACUPUNCTURE AND HERBAL HEALING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-396-5375
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:BEULAH
Mailing Address - State:CO
Mailing Address - Zip Code:81023-0296
Mailing Address - Country:US
Mailing Address - Phone:719-396-5375
Mailing Address - Fax:
Practice Address - Street 1:1307 FORTINO BLVD STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2032
Practice Address - Country:US
Practice Address - Phone:719-582-1010
Practice Address - Fax:719-631-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001916171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty