=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720640964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLINE GEORGETTI LIC. AC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 E MAIN ST STE 5
-----------------------------------------------------
City | MYSTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06355-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-464-4888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 CLIPPER DR
-----------------------------------------------------
City | MYSTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06355-1996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-326-4335
-----------------------------------------------------
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 | 43000753
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------