=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821573924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMIE LEIH GUERRA LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2018
-----------------------------------------------------
Last Update Date | 09/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5991 E FOREST ST
-----------------------------------------------------
City | APACHE JUNCTION
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85119-9891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-687-0144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5991 E FOREST ST
-----------------------------------------------------
City | APACHE JUNCTION
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85119-9891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-687-0144
-----------------------------------------------------
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 | LAC-010010
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------