=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316352321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED INTEGRATIVE MEDICAL THERAPIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2014
-----------------------------------------------------
Last Update Date | 06/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 428 E 5TH AVE
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757-5663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-383-0004
-----------------------------------------------------
Fax | 352-735-8637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 428 E 5TH AVE
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757-5663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-383-0004
-----------------------------------------------------
Fax | 352-735-8637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VICTORIA R MILLER
-----------------------------------------------------
Credential | DOM
-----------------------------------------------------
Telephone | 352-383-0004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 1397
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------