=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992107890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENISE DOUGLAS DBA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2014
-----------------------------------------------------
Last Update Date | 09/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 E OAKLAND PARK BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33306-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-907-9787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 E OAKLAND PARK BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33306-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-907-9787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DENISE DOUGLAS
-----------------------------------------------------
Credential | A.P
-----------------------------------------------------
Telephone | 954-907-9787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP2412
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------