Provider Demographics
NPI:1396047403
Name:ACUPUNCTURE WELLNESS MEDICAL CLINIC
Entity type:Organization
Organization Name:ACUPUNCTURE WELLNESS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF ORIENTAL MEDICINE
Authorized Official - Prefix:MS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:L, AC , DOM,
Authorized Official - Phone:941-586-4064
Mailing Address - Street 1:400 TAMIAMI TRL S STE 150
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-2623
Mailing Address - Country:US
Mailing Address - Phone:941-586-4064
Mailing Address - Fax:
Practice Address - Street 1:400 TAMIAMI TRL S STE 150
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2623
Practice Address - Country:US
Practice Address - Phone:941-586-4064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2422261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care