=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396097762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOWLING COMMUNITY ACUPUNCTURE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2012
-----------------------------------------------------
Last Update Date | 10/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 MILWAUKEE AVE SUITE A
-----------------------------------------------------
City | SOUTH MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53172-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-762-5775
-----------------------------------------------------
Fax | 414-762-5895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 911 MILWAUKEE AVE SUITE A
-----------------------------------------------------
City | SOUTH MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53172-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-762-5775
-----------------------------------------------------
Fax | 414-762-5895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. LORAN EZRA DOWLING JR.
-----------------------------------------------------
Credential | MSOM
-----------------------------------------------------
Telephone | 414-762-5775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 454055
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------