Healthcare Provider Details

I. General information

NPI: 1457895757
Provider Name (Legal Business Name): DONG YO ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 PALM BAY RD NE STE 2
PALM BAY FL
32905-2937
US

IV. Provider business mailing address

2105 PALM BAY RD NE STE 2
PALM BAY FL
32905-2937
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-3017
  • Fax:
Mailing address:
  • Phone: 321-723-3017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP1352
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberAC164809
License Number StateOR

VIII. Authorized Official

Name: SUSAN JEAN HATHAWAY
Title or Position: ACUPUNCTURIST
Credential: DAOM
Phone: 321-723-3017