=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801334511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URBAN ACUPUNCTURE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2017
-----------------------------------------------------
Last Update Date | 02/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 N WACKER DR 4TH FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60606-1787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-727-5042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3166 N LINCOLN AVE SUITE 405
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-727-5042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYLA BOLES
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 773-727-5042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 198.000840
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------