=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790188449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACUPUNCTURE & THERAPEUTIC MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2014
-----------------------------------------------------
Last Update Date | 10/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 E LAKESHORE DR STE 102
-----------------------------------------------------
City | MANISTIQUE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49854-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-286-0198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 E LAKESHORE DR STE 102
-----------------------------------------------------
City | MANISTIQUE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49854-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-286-0198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST, OWNER
-----------------------------------------------------
Name | DR. GEORGANNE ROBERTA VERIGAN
-----------------------------------------------------
Credential | L.AC, PHD
-----------------------------------------------------
Telephone | 906-286-0198
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 540100068
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------