MEDICARE: SHEN RADIANCE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1164286753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEN RADIANCE, LLC

Provider Business Mailing Address
First Line	:	55 VILLAGE RD
Second Line	:
City	:	POMPTON PLAINS
State	:	NJ
Zip	:	07444-1829
Country	:	US
Telephone Number	:	914-482-3945
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 CHURCH ST STE L4
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-2745
Country	:	US
Telephone Number	:	914-482-3945
Fax Number	:

Authorized Official
Title or Position	:	ACUPUNCTURIST/OWNER
Name	:	DR. FATMA MINHAS-KUCUK
Credential	:	DAC, LAC
Telephone Number	:	914-482-3945

Provider Enumeration Date	:	02/13/2024
Last Update Date	:	02/13/2024

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