=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730947243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GLOW STUDIO ACUPUNCTURE, PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2024
-----------------------------------------------------
Last Update Date | 03/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 HILL RD STE G
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-761-1440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 624 CANYON RD
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-739-2457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LORRIE B FISSENDEN
-----------------------------------------------------
Credential | L.AC., MSTCM
-----------------------------------------------------
Telephone | 816-739-2457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------