Healthcare Provider Details

I. General information

NPI: 1275207375
Provider Name (Legal Business Name): AMAD JOHN ELIA LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 EDGERTOWN- VINEYARD HAVEN RD
EDGERTOWN MA
02539
US

IV. Provider business mailing address

21 HENRY ST
NORTHAMPTON MA
01060-2518
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-3800
  • Fax: 508-693-7473
Mailing address:
  • Phone: 248-703-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5401000142
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: