Healthcare Provider Details

I. General information

NPI: 1740429984
Provider Name (Legal Business Name): FOUR WINDS ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E GRANADA BLVD STE 1
ORMOND BEACH FL
32176-6634
US

IV. Provider business mailing address

115 E GRANADA BLVD STE 1
ORMOND BEACH FL
32176-6634
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-5400
  • Fax: 386-677-5420
Mailing address:
  • Phone: 386-677-5400
  • Fax: 386-677-5420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP2427
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA35023
License Number StateFL

VIII. Authorized Official

Name: JEAN S CARON
Title or Position: PRESIDENT
Credential: DOM, AP, LMT
Phone: 386-677-5400