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General NPI Number Information
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NPI Number | 1699197103
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Entity Type | Organization
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Legal Business Name | JADE MOUNTAIN WELLNESS, INC.
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Dates
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Enumeration Date | 01/17/2014
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Last Update Date | 01/17/2014
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Provider Practice Location Address
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Address Line | 1 MILL ST SUITE 305
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City | BURLINGTON
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State | VT
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Zip | 05401-1530
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Country | US
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Telephone | 802-399-2102
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Fax |
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Provider Business Mailing Address
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Address Line | 1 MILL ST SUITE 305
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City | BURLINGTON
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State | VT
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Zip | 05401-1530
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Country | US
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Telephone | 802-399-2102
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Fax |
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Authorized Official
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Title or Position | ACUPUNCTURIST
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Name | MR. BRENDAN KELLY
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Credential | L. AC,
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Telephone | 802-399-2102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 0910000151
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License Number State | VT
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