=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346926441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHTOWNS ACUPUNCTURE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2023
-----------------------------------------------------
Last Update Date | 06/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4390 QUINBY DRIVE SUITE F
-----------------------------------------------------
City | HAMBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14075-7900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-412-1213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5441 OLD LAKE SHORE RD
-----------------------------------------------------
City | LAKE VIEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14085-9751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-412-1213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST/COMPANY OWNER
-----------------------------------------------------
Name | MS. TRACY LYNN RUDNICKI
-----------------------------------------------------
Credential | L.AC., MS
-----------------------------------------------------
Telephone | 530-412-1213
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------