=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205002987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE WELL ACUPUNCTURE P. C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2008
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 59TH ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-4837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-440-1189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4011 59TH ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-4837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARIA GILANY TOM
-----------------------------------------------------
Credential | L. AC.
-----------------------------------------------------
Telephone | 718-440-1189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 003439
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------