=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679000467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORLANDO HOLISTIC ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2221 LEE RD SUITE 14
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-683-3995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2221 LEE RD SUITE 14
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-683-3995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURE PHYSICIAN
-----------------------------------------------------
Name | MR. JIGNESH PANCHAL
-----------------------------------------------------
Credential | A.P., DOM
-----------------------------------------------------
Telephone | 407-683-3995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP2946
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------