=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447547542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACUPUNCTURE STUDIO OF SAN RAFAEL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2011
-----------------------------------------------------
Last Update Date | 07/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 526 3RD ST STE C1
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-488-3932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 GRANDE PASEO
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94903-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-328-6098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST, CO FOUNDER
-----------------------------------------------------
Name | MISS AMBER SCRIVEN
-----------------------------------------------------
Credential | MS LAC
-----------------------------------------------------
Telephone | 415-488-3932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC13882
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------