Provider Demographics
NPI:1962820456
Name:FULL WELL ACUPUNCTURE LLC
Entity type:Organization
Organization Name:FULL WELL ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGG FLAX
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-690-8048
Mailing Address - Street 1:838 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3965
Mailing Address - Country:US
Mailing Address - Phone:505-690-8048
Mailing Address - Fax:
Practice Address - Street 1:838 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3965
Practice Address - Country:US
Practice Address - Phone:505-690-8048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1072261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center