Provider Demographics
NPI:1336676022
Name:STONE MOUNTAIN MEDICINE-ACUPUNCTURE
Entity Type:Organization
Organization Name:STONE MOUNTAIN MEDICINE-ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-549-9905
Mailing Address - Street 1:1533 SHATTUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1516
Mailing Address - Country:US
Mailing Address - Phone:510-549-9905
Mailing Address - Fax:
Practice Address - Street 1:1533 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1516
Practice Address - Country:US
Practice Address - Phone:510-549-9905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8691261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center