Healthcare Provider Details

I. General information

NPI: 1568996403
Provider Name (Legal Business Name): FLYING TURTLE HEALING ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 ELM ST SUITE 300B
SOMERVILLE MA
02144-2950
US

IV. Provider business mailing address

259 ELM ST SUITE 300B
SOMERVILLE MA
02144-2950
US

V. Phone/Fax

Practice location:
  • Phone: 617-294-9109
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number253925
License Number StateMA

VIII. Authorized Official

Name: FANNIE KOA
Title or Position: OWNER/PRACTITIONER
Credential: LAC., MAOM, DIPL.OM
Phone: 617-294-9109