=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619038338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUR GATES ORIENTAL MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1189 SW 26TH AVE
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-326-7310
-----------------------------------------------------
Fax | 954-797-0331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5311 SW 90TH AVE
-----------------------------------------------------
City | COOPER CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-5112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-326-7310
-----------------------------------------------------
Fax | 954-680-6728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CLAIRE E FITCH
-----------------------------------------------------
Credential | ACUP PHYSICIAN
-----------------------------------------------------
Telephone | 954-326-7310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP 1706
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------