Provider Demographics
NPI:1689013740
Name:EDGEWATER ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:EDGEWATER ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MEAGHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSELLA WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, LAC, DIPL AC
Authorized Official - Phone:443-540-3350
Mailing Address - Street 1:153 MAYO RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1852
Mailing Address - Country:US
Mailing Address - Phone:443-540-3350
Mailing Address - Fax:
Practice Address - Street 1:153 MAYO RD
Practice Address - Street 2:SUITE 5
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1852
Practice Address - Country:US
Practice Address - Phone:443-540-3350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01561171100000X
MDU01597171100000X
MDU02034171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty