=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043655202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN JADE ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2013
-----------------------------------------------------
Last Update Date | 05/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13700 ALTON PKWY SUITE 158
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-278-3642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13700 ALTON PKWY SUITE 158
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-278-3642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CHRIS CHARLES BRUCKNER
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 949-278-3642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 15129
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------