=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245599281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSONVILLE ACUPUNCTURE WELLNESS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2012
-----------------------------------------------------
Last Update Date | 05/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3016 3RD ST S SUITE 102
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-6011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-859-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 ARBOR CLUB DR SUITE #216
-----------------------------------------------------
City | PONTE VEDRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-859-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. KIMBERLY RUEL
-----------------------------------------------------
Credential | AP
-----------------------------------------------------
Telephone | 904-859-5333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP2548
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------