=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164784583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLEGHENY HOLISTIC HEALTH CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 FAIRFAX AVENUE
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26260-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-516-7251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 631
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26260-0631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | JENNIFER WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-516-7251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 96213
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------