Provider Demographics
NPI:1316423155
Name:BODY & SOUL ACUPUNCTURE LLC
Entity type:Organization
Organization Name:BODY & SOUL ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ACUPUNCTURIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:ELYNN
Authorized Official - Last Name:WILTON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MAC
Authorized Official - Phone:860-881-7449
Mailing Address - Street 1:5419 DEALE CHURCHTON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CHURCHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20733-2408
Mailing Address - Country:US
Mailing Address - Phone:860-881-7449
Mailing Address - Fax:
Practice Address - Street 1:5419 DEALE CHURCHTON RD STE 104
Practice Address - Street 2:
Practice Address - City:CHURCHTON
Practice Address - State:MD
Practice Address - Zip Code:20733-2408
Practice Address - Country:US
Practice Address - Phone:860-881-7449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty