MEDICARE: ONSITE HOLISTICS AND INTEGRATIVE MEDICINE, LLC

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 3478	FL

General Provider Information

NPI Number	:	1407388150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONSITE HOLISTICS AND INTEGRATIVE MEDICINE, LLC

Provider Business Mailing Address
First Line	:	4409 HOFFNER AVE
Second Line	:	# 258
City	:	ORLANDO
State	:	FL
Zip	:	32812-2331
Country	:	US
Telephone Number	:	407-490-3812
Fax Number	:

Provider Business Practice Location Address
First Line	:	4409 HOFFNER AVE
Second Line	:	# 258
City	:	ORLANDO
State	:	FL
Zip	:	32812-2331
Country	:	US
Telephone Number	:	407-490-3812
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOSHUAH C JACKSON
Credential	:	DOM
Telephone Number	:	407-490-3852

Provider Enumeration Date	:	03/31/2017
Last Update Date	:	03/31/2017

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