=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598067571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRADITIONAL ACUPUNCTURE SERVICES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2010
-----------------------------------------------------
Last Update Date | 04/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15800 PINES BLVD SUITE 329
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-200-4587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15800 PINES BLVD SUITE 329
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-200-4587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER/ACUPUNCTURE PHYSICIAN
-----------------------------------------------------
Name | DR. SANDRA MORA-VIERA
-----------------------------------------------------
Credential | DOM, MD (COLOMBIA)
-----------------------------------------------------
Telephone | 954-200-4587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 2891
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------