1346685344 NPI number — RED LOTUS ACUPUNCTURE AND ORIENTAL MEDICINE

Table of content: MS. STACY ALBERT JERRETT LPC (NPI 1154597326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346685344 NPI number — RED LOTUS ACUPUNCTURE AND ORIENTAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED LOTUS ACUPUNCTURE AND ORIENTAL MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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NPI Number Information

NPI Number:
1346685344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6530 NEEDHAM LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78739-1512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8303 SHOAL CREEK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78757-7525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-797-7151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS MATTSON
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
L.AC.
Authorized Official Telephone Number:
512-797-7151

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  TX AC00674 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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