=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447627930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBUS ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2015
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2520 CALIFORNIA ST STE G
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47201-3677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-374-4518
-----------------------------------------------------
Fax | 800-774-0150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2520 CALIFORNIA ST STE G
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47201-3677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-374-4518
-----------------------------------------------------
Fax | 800-774-0150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRYCE UTT
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 812-374-4518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 84000145A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------