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General NPI Number Information
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NPI Number | 1063846574
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Entity Type | Organization
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Legal Business Name | LM AT BLUEGREEN
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Dates
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Enumeration Date | 09/03/2013
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 301 W 29TH ST SUITE 2001
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City | BALTIMORE
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State | MD
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Zip | 21211-2910
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Country | US
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Telephone | 443-388-1110
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Fax |
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Provider Business Mailing Address
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Address Line | 301 W 29TH ST SUITE 2001
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City | BALTIMORE
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State | MD
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Zip | 21211-2910
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Country | US
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Telephone | 443-388-1110
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | LEONORA GEVAERD MANEKIN
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Credential | LAC, MAC
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Telephone | 443-388-1110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | U01822
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License Number State | MD
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