=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326054271
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEFANIE MARIE BENNETT LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18046 MAGNOLIA
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-962-5031
-----------------------------------------------------
Fax | 714-962-5039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18627 BROOKHURST #507
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-962-5031
-----------------------------------------------------
Fax | 714-962-5039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC9255
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------