=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790182616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BG MANCINI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2014
-----------------------------------------------------
Last Update Date | 11/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2142 NE 123RD ST
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33181-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-206-0638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2142 NE 123RD ST
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33181-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-206-0638
-----------------------------------------------------
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 | 3390
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------