=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780134635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL BONACCI M.S., L.AC.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2016
-----------------------------------------------------
Last Update Date | 10/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 NASSAU ST SUITE 206
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08542-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-751-4654
-----------------------------------------------------
Fax | 609-228-5839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 DEVONSHIRE CT
-----------------------------------------------------
City | EWING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08628-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-751-4654
-----------------------------------------------------
Fax | 609-228-5839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 25MZ00122400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------