=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649703398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOURCE ACUPUNCTURE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2017
-----------------------------------------------------
Last Update Date | 04/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 4TH ST
-----------------------------------------------------
City | HOBOKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07030-4837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-526-4684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 4TH ST
-----------------------------------------------------
City | HOBOKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07030-4837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-526-4684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, ACUPUNCTURIST
-----------------------------------------------------
Name | ARIELE MYERS
-----------------------------------------------------
Credential | L.AC
-----------------------------------------------------
Telephone | 201-526-4684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 25MZ00048500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------