=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720123011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YAN XU LICENSED ACUPUNCTURI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 REEF RD SUITE 110
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-256-8999
-----------------------------------------------------
Fax | 203-256-9886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 PRATT STREET
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-259-7768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 000303
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 001383
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------