=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063996239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAINNE MCKEOWN ACUPUNCTURE CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2018
-----------------------------------------------------
Last Update Date | 03/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 W WELLINGTON AVE STE 220
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-7187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-338-2309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 W WELLINGTON AVE STE 220
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-7187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-338-2309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | MS. GRAINNE MCKEOWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-338-2309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------