Healthcare Provider Details

I. General information

NPI: 1316423155
Provider Name (Legal Business Name): BODY & SOUL ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 DEALE CHURCHTON RD STE 104
CHURCHTON MD
20733-2408
US

IV. Provider business mailing address

5419 DEALE CHURCHTON RD STE 104
CHURCHTON MD
20733-2408
US

V. Phone/Fax

Practice location:
  • Phone: 860-881-7449
  • Fax:
Mailing address:
  • Phone: 860-881-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02143
License Number StateMD

VIII. Authorized Official

Name: MRS. TAMARA ELYNN WILTON
Title or Position: OWNER/ACUPUNCTURIST
Credential: L.AC., M.AC.
Phone: 860-881-7449