=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386293520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMARA TCM ACUPUNCTURE & HERBS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2019
-----------------------------------------------------
Last Update Date | 09/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W DUDLEY ST
-----------------------------------------------------
City | MAUMEE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43537-2141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-345-4996
-----------------------------------------------------
Fax | 877-961-4515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W DUDLEY ST
-----------------------------------------------------
City | MAUMEE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43537-2141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-345-4996
-----------------------------------------------------
Fax | 877-961-4515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. SCOTT BRADLEY MCBRIDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-345-4996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------