=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578701959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOUTIQUE ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2009
-----------------------------------------------------
Last Update Date | 07/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 PROFESSIONAL DR
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-2164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-473-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 PROFESSIONAL DR
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-2164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-473-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MATTHEW NADEAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-473-7602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 338854
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------