Provider Demographics
NPI:1730588591
Name:SWEET GRASS ACUPUNCTURE & WELLNESS
Entity type:Organization
Organization Name:SWEET GRASS ACUPUNCTURE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MSOM
Authorized Official - Phone:307-856-8800
Mailing Address - Street 1:604 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3338
Practice Address - Country:US
Practice Address - Phone:307-856-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYACU 0001990171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty