Healthcare Provider Details

I. General information

NPI: 1588064778
Provider Name (Legal Business Name): PENTHOUSE ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 CENTERPOINTE CIR SUITE 1647
ALTAMONTE SPRINGS FL
32701-3456
US

IV. Provider business mailing address

407 CENTERPOINTE CIR SUITE 1647
ALTAMONTE SPRINGS FL
32701-3456
US

V. Phone/Fax

Practice location:
  • Phone: 407-439-5078
  • Fax: 407-264-6798
Mailing address:
  • Phone: 407-439-5078
  • Fax: 407-264-6798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP2423
License Number StateFL

VIII. Authorized Official

Name: MR. MANOUCHEHR EGHBAL
Title or Position: OWNER
Credential: LAC
Phone: 407-439-5078