=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447649702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTSIDE ACUPUNCTURE & MASSAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2015
-----------------------------------------------------
Last Update Date | 01/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4824 MCMAHON BLVD NW STE 113
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-890-9378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6119 MUSTANG LN NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87120-2289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRIAN CAREY
-----------------------------------------------------
Credential | DOM
-----------------------------------------------------
Telephone | 505-890-9378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 869
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------