=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053672246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETRA FOO L.AC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2012
-----------------------------------------------------
Last Update Date | 06/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1641 N MILWAUKEE AVE #9
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-1350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-971-9393
-----------------------------------------------------
Fax | 847-929-9568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1641 N MILWAUKEE AVE #9
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-1350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-971-9393
-----------------------------------------------------
Fax | 847-929-9568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 198000516
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------