Healthcare Provider Details

I. General information

NPI: 1093167991
Provider Name (Legal Business Name): GARDEN STATE ACUPUNCTURE AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 ROUTE 34 SUITE 210
COLTS NECK NJ
07722-2522
US

IV. Provider business mailing address

1116 5TH AVE
ASBURY PARK NJ
07712-4905
US

V. Phone/Fax

Practice location:
  • Phone: 302-249-0143
  • Fax: 732-775-3515
Mailing address:
  • Phone: 302-249-0143
  • Fax: 732-775-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00104200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT00938000
License Number StateNJ

VIII. Authorized Official

Name: DR. KEVIN CLARK
Title or Position: OWNER
Credential: DAOM, L.AC.
Phone: 302-249-0143