=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205402153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IN BLOOM ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2021
-----------------------------------------------------
Last Update Date | 06/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 N 30TH ST STE C
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98403-3361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-265-5116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 N 30TH ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98403-3361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ACUPUNCTURIST
-----------------------------------------------------
Name | TARA MCCORMICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-265-5116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------