Healthcare Provider Details

I. General information

NPI: 1881203024
Provider Name (Legal Business Name): BANTAM ACUPUNCTURE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 BANTAM RD
BANTAM CT
06750-1600
US

IV. Provider business mailing address

622 BANTAM RD
BANTAM CT
06750-1600
US

V. Phone/Fax

Practice location:
  • Phone: 802-373-2352
  • Fax:
Mailing address:
  • Phone: 802-373-2352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NIKHIL RAMBURN
Title or Position: OWNER
Credential: DAC
Phone: 802-373-2352