MEDICARE: PHOENIX RISES ACUPUNCTURE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AP 3712	FL

General Provider Information

NPI Number	:	1326494006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX RISES ACUPUNCTURE

Provider Business Mailing Address
First Line	:	150 KENT RD
Second Line	:	SUITE 2A
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-6350
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 KENT RD
Second Line	:	SUITE 2A
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-6350
Country	:	US
Telephone Number	:	904-238-1000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GORDANA SMITH
Credential	:	LAC
Telephone Number	:	904-238-1000

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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