MEDICARE: MS. LARISSA GAY STEWART 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	333	GA

General Provider Information

NPI Number	:	1821493735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LARISSA GAY STEWART L.AC.

Provider Business Mailing Address
First Line	:	2515 19TH AVE APT A
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-1374
Country	:	US
Telephone Number	:	229-603-3332
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 WYNNTON RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31906-2407
Country	:	US
Telephone Number	:	762-221-5403
Fax Number	:

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

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	09/10/2019

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