=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326392788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODY EVOLUTION ACUPUNCTURE AND WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2012
-----------------------------------------------------
Last Update Date | 11/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4111 MARATHON BLVD SUITE 110
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78756-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-522-7405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 SANDRA MURAIDA WAY APT. 329
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78703-4696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-512-6850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, ACUPUNCTURIST
-----------------------------------------------------
Name | MS. JENNIFER STANG
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 512-522-7405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC01374
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------