=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831483601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACUPUNCTURE & WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2011
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5550 STERRETT PL SUITE 303
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-997-0390
-----------------------------------------------------
Fax | 410-885-4744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5550 STERRETT PL SUITE 303
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-997-0390
-----------------------------------------------------
Fax | 410-885-4744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR/OWNER
-----------------------------------------------------
Name | SEOK PARK
-----------------------------------------------------
Credential | PH.D., L.AC.
-----------------------------------------------------
Telephone | 410-997-0390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | U01592
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------