Healthcare Provider Details

I. General information

NPI: 1164109815
Provider Name (Legal Business Name): THOMAS AUSTIN-BRAXTON LAC., MAC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 11/05/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11350 MCCORMICK RD STE 800
HUNT VALLEY MD
21031-1002
US

IV. Provider business mailing address

7700 OLD HARFORD RD
PARKVILLE MD
21234-6313
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-2169
  • Fax:
Mailing address:
  • Phone: 410-870-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU03005
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: