=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407251838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACUPUNCTURE COLLECTIVELLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2014
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 N KENTUCKY ST
-----------------------------------------------------
City | SILVER CITY
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88061-3925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-920-8339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2024 HOPI RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-920-8339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KATHLEEN M. CAMPBELL
-----------------------------------------------------
Credential | DOM
-----------------------------------------------------
Telephone | 505-920-8339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 168
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------