=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295288959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTSHINE ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2016
-----------------------------------------------------
Last Update Date | 07/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3110 W SPRINGS DR APT F
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21043-3249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-564-6303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3110 W SPRINGS DR APT F
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21043-3249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-564-6303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST
-----------------------------------------------------
Name | VICTORIA BRUK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-564-6303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | U02326
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------