=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265062889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIDDEN WELL ACUPUNCTURE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2020
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 HOUSTON ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31401-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-233-9123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 HOUSTON ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31401-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-233-9123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & PRACTITIONER
-----------------------------------------------------
Name | FAWN DEMOISELLE SMILEY
-----------------------------------------------------
Credential | ACUPUNCTURIST
-----------------------------------------------------
Telephone | 912-233-9123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------