=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215399217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX RISING: ADRIAN WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2016
-----------------------------------------------------
Last Update Date | 03/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W MAUMEE ST
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49221-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-759-4018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 W MAUMEE ST
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49221-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-759-4018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. ELIZABETH L STEWART
-----------------------------------------------------
Credential | ACUPUNCTURE PHYSICIA
-----------------------------------------------------
Telephone | 517-759-4018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 5401000096
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------