=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366920407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAHLAQA SHAHEN QURESHI LAC,MAO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2018
-----------------------------------------------------
Last Update Date | 07/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1217 W STATE HIGHWAY 114 STE 124
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-3995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-592-2494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 W RENNER RD APT 2415
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-592-2494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC01797
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------