Healthcare Provider Details

I. General information

NPI: 1831304716
Provider Name (Legal Business Name): GEORGE MASON LIC. AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 BORLAND HILL RD
NOBLEBORO ME
04555-8814
US

IV. Provider business mailing address

123 BORLAND HILL RD
NOBLEBORO ME
04555-8814
US

V. Phone/Fax

Practice location:
  • Phone: 207-563-5754
  • Fax: 207-563-6302
Mailing address:
  • Phone: 207-563-5754
  • Fax: 207-563-6302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC191
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: