=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144657974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEWOOD RANCH ACUPUNCTURE AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2013
-----------------------------------------------------
Last Update Date | 10/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11061 GATEWOOD DR UNIT 103
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-518-6237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11061 GATEWOOD DR UNIT 103
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-518-6237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURE PHYSICIAN
-----------------------------------------------------
Name | DR. AMANDA CARTER
-----------------------------------------------------
Credential | A.P., D.O.M
-----------------------------------------------------
Telephone | 941-518-6237
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 3078
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------