MEDICARE: SOUTHSIDE ACUPUNCTURE, PLLC

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	AC01294	TX

General Provider Information

NPI Number	:	1568743102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE ACUPUNCTURE, PLLC

Provider Business Mailing Address
First Line	:	3010 6TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-3434
Country	:	US
Telephone Number	:	817-913-2421
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 8TH AVE
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1352
Country	:	US
Telephone Number	:	817-913-2421
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LICENSED ACUPUNCTURIST
Name	:	CAMERON M SZOK
Credential	:	L.AC.
Telephone Number	:	817-913-2421

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	04/18/2016

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