Healthcare Provider Details

I. General information

NPI: 1508613241
Provider Name (Legal Business Name): AMY SOO KEMPER L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 MAIN STREET
GLADSTONE NJ
07934
US

IV. Provider business mailing address

30 HARRY RD
BRIDGEWATER NJ
08807-3152
US

V. Phone/Fax

Practice location:
  • Phone: 646-801-1308
  • Fax:
Mailing address:
  • Phone: 848-221-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00171300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: