=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366795676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN BALANCE ORIENTAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2012
-----------------------------------------------------
Last Update Date | 10/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2539 S GESSNER RD SUITE 15
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-922-8179
-----------------------------------------------------
Fax | 832-843-0317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2539 S GESSNER RD SUITE 15
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-922-8179
-----------------------------------------------------
Fax | 832-843-0317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELLEN GONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-922-8179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC00748
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------