=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336772276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACUPUNCTURE TREE OF LIFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2020
-----------------------------------------------------
Last Update Date | 02/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 FARMINGTON AVE APT 1
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06053-5901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-573-8047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 FARMINGTON AVE
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06053-1652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MAEGAN BETENVIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-573-1736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------