Healthcare Provider Details

I. General information

NPI: 1477096741
Provider Name (Legal Business Name): ELEMENTAL SOURCE ACUPUNCTURE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 W PATRICK ST SUITE 2
FREDERICK MD
21701-6910
US

IV. Provider business mailing address

3627 LEW WALLACE ST
FREDERICK MD
21704-7872
US

V. Phone/Fax

Practice location:
  • Phone: 240-432-7522
  • Fax:
Mailing address:
  • Phone: 240-432-7522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KALLIE GUIMOND
Title or Position: OWNER/LICENSED ACUPUNCTURIST
Credential: M.OM
Phone: 240-432-7522