=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255193876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT SHEN ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 142 S GARY AVE STE 111
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108-2226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-648-7990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1808 MARYLAND DR
-----------------------------------------------------
City | ELK GROVE VILLAGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60007-2734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-648-7990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | MRS. KINGA VAN BRUNT
-----------------------------------------------------
Credential | LAC.
-----------------------------------------------------
Telephone | 847-648-7990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------