=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952861122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AQU WELLNESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2019
-----------------------------------------------------
Last Update Date | 03/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 VIA DE LA PAZ STE 201
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-258-4292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 VIA DE LA PAZ STE 201
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-258-4292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST/OWNER
-----------------------------------------------------
Name | SAMANTHA LEIGH MANKA-SEGAL
-----------------------------------------------------
Credential | L.AC
-----------------------------------------------------
Telephone | 424-258-4292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------