=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043978059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTINA WALLACE ACUPUNCTURE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2021
-----------------------------------------------------
Last Update Date | 12/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S. BROADWAY SOUTH BUILDING, SUITE #2-3
-----------------------------------------------------
City | TARRYTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10591-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-246-0148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 LYMAN AVE
-----------------------------------------------------
City | PEEKSKILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10566-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-246-0148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. CHRISTINA WALLACE
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 914-246-0148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------