=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477096741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEMENTAL SOURCE ACUPUNCTURE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2016
-----------------------------------------------------
Last Update Date | 11/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 263 W PATRICK ST SUITE 2
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-6910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-432-7522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3627 LEW WALLACE ST
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21704-7872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-432-7522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED ACUPUNCTURIST
-----------------------------------------------------
Name | KALLIE GUIMOND
-----------------------------------------------------
Credential | M.OM
-----------------------------------------------------
Telephone | 240-432-7522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------