Healthcare Provider Details

I. General information

NPI: 1740100098
Provider Name (Legal Business Name): PURPLE CLOVER ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PLEASANT ST APT 324
MALDEN MA
02148-3081
US

IV. Provider business mailing address

75 PLEASANT ST APT 324
MALDEN MA
02148-3081
US

V. Phone/Fax

Practice location:
  • Phone: 770-335-1707
  • Fax:
Mailing address:
  • Phone: 770-335-1707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: CORY D SHAMBLIN
Title or Position: OWNER
Credential:
Phone: 770-335-1707