MEDICARE: MISS MARY ELLEN MARTIN LAC

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	171100000X	Acupuncturist	25002586	NY

General Provider Information

NPI Number	:	1538212121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARY ELLEN MARTIN LAC

Provider Business Mailing Address
First Line	:	17 MICHIGAN ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1306
Country	:	US
Telephone Number	:	646-942-8164
Fax Number	:	631-928-2045

Provider Business Practice Location Address
First Line	:	1015 W BEECH ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1203
Country	:	US
Telephone Number	:	646-942-8164
Fax Number	:	631-928-2045

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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Directions to “ MISS MARY ELLEN MARTIN LAC” Practice Location

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