MEDICARE: OLIVIA MADDOCK L.AC.

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	006810	NY

General Provider Information

NPI Number	:	1407457732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA MADDOCK L.AC.

Provider Business Mailing Address
First Line	:	82 WASHINGTON ST
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-6544
Country	:	US
Telephone Number	:	315-879-7416
Fax Number	:

Provider Business Practice Location Address
First Line	:	84 SWEENEY ST STE 1
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-5822
Country	:	US
Telephone Number	:	716-694-2225
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	08/26/2021

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