=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194957571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC RECINE L.A.C. C.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2009
-----------------------------------------------------
Last Update Date | 08/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 BROOKWOOD DR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-496-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W7417 BUTTERFLY LN
-----------------------------------------------------
City | SHIOCTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54170-8898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-915-9882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 639055
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------