=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629460936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYLIE HUEY ACUPUNCTURE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2015
-----------------------------------------------------
Last Update Date | 02/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2345 PARK BLVD
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94606-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-698-9037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2345 PARK BLVD
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94606-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WYLIE HUEY
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 510-698-9037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 15301
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 16255
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 14803
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------