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General NPI Number Information
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NPI Number | 1780083550
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Entity Type | Organization
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Legal Business Name | BLOSSOM ACUPUNCTURE & WELLNESS
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Dates
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Enumeration Date | 08/18/2014
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Last Update Date | 08/18/2014
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Provider Practice Location Address
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Address Line | 11651 JOLLYVILLE RD STE 150
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City | AUSTIN
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State | TX
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Zip | 78759-4106
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Country | US
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Telephone | 512-850-5697
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Fax |
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Provider Business Mailing Address
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Address Line | 2008 SIMOND AVE APT D
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City | AUSTIN
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State | TX
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Zip | 78723-4555
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/ACUPUNCTURIST
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Name | JENNIE STILES BALDWIN
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Credential | LAC
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Telephone | 512-850-5697
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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 | 01458
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License Number State | TX
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