Healthcare Provider Details

I. General information

NPI: 1336676022
Provider Name (Legal Business Name): STONE MOUNTAIN MEDICINE-ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 SHATTUCK AVE
BERKELEY CA
94709-1516
US

IV. Provider business mailing address

1533 SHATTUCK AVE
BERKELEY CA
94709-1516
US

V. Phone/Fax

Practice location:
  • Phone: 510-549-9905
  • Fax:
Mailing address:
  • Phone: 510-549-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number8691
License Number StateCA

VIII. Authorized Official

Name: MICHAEL FITZGERALD
Title or Position: LICENSED ACUPUNCTURIST
Credential:
Phone: 510-549-9905