=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881203024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BANTAM ACUPUNCTURE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2020
-----------------------------------------------------
Last Update Date | 07/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 624 BANTAM RD
-----------------------------------------------------
City | BANTAM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06750-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-373-2352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 622 BANTAM RD
-----------------------------------------------------
City | BANTAM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06750-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-373-2352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NIKHIL RAMBURN
-----------------------------------------------------
Credential | DAC
-----------------------------------------------------
Telephone | 802-373-2352
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------