=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710274675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY ACUPUNCTURE & YOGA ARTS CENTRE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2011
-----------------------------------------------------
Last Update Date | 06/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 E ASPEN AVE
-----------------------------------------------------
City | FRUITA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81521-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-858-6635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 E ASPEN AVE
-----------------------------------------------------
City | FRUITA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81521-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-858-6635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED ACUPUNCTURIST & HERBALIST
-----------------------------------------------------
Name | DR. TARA DEVI MALHOTRA
-----------------------------------------------------
Credential | L.AC., OMD(FL)
-----------------------------------------------------
Telephone | 970-858-6635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 1601
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------