Healthcare Provider Details

I. General information

NPI: 1952428708
Provider Name (Legal Business Name): JOHN ANTHONY CHARLEBOIS L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 WASHINGTON AVE
PORTLAND ME
04101-2632
US

IV. Provider business mailing address

218 WASHINGTON AVE
PORTLAND ME
04101-2632
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-7778
  • Fax: 207-773-5773
Mailing address:
  • Phone: 207-773-7778
  • Fax: 207-773-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 200
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: