Provider Demographics
NPI:1710106158
Name:ACUPUNCTURE CLINIC
Entity Type:Organization
Organization Name:ACUPUNCTURE CLINIC
Other - Org Name:ADVANCED HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JALIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BARADARAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:361-991-0460
Mailing Address - Street 1:5705 GOLLIHAR
Mailing Address - Street 2:STE 2
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412
Mailing Address - Country:US
Mailing Address - Phone:361-991-0460
Mailing Address - Fax:361-992-1094
Practice Address - Street 1:5705 GOLLIHAR
Practice Address - Street 2:STE 2
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412
Practice Address - Country:US
Practice Address - Phone:361-991-0460
Practice Address - Fax:361-992-1094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACUPUNCTURE CLINIC DBA ADVANCED HEALTH CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-24
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6152111N00000X
TXAC138171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00396XOtherGROUP #
U42225Medicare UPIN
TX8C6203Medicare ID - Type Unspecified
8C6203Medicare PIN