MEDICARE: MAYNARD CLINIC OF ACUPUNCTURE & ORIENTAL MEDICINE

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	004865	NY
2	171100000X	Acupuncturist	25MZ00094000	NJ

General Provider Information

NPI Number	:	1386997823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYNARD CLINIC OF ACUPUNCTURE & ORIENTAL MEDICINE

Provider Business Mailing Address
First Line	:	22 SYLVAN ST
Second Line	:	SUITE 200
City	:	RUTHERFORD
State	:	NJ
Zip	:	07070-2087
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 SYLVAN ST
Second Line	:	SUITE 200
City	:	RUTHERFORD
State	:	NJ
Zip	:	07070-2087
Country	:	US
Telephone Number	:	917-941-5180
Fax Number	:

Authorized Official
Title or Position	:	ACUPUNCTURIST
Name	:	MR. DARREN WALDRON MAYNARD
Credential	:	LAC
Telephone Number	:	917-941-5180

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	10/22/2012

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